Publications & Products

Operations Research Reports

Each report describes an operations research study carried out by QAP that provides findings or methods that could contribute to efforts to improve the delivery of healthcare services in developing countries.

Accreditation and Quality Regulation

The Impact of Accreditation on the Quality of Hospital Care: KwaZulu-Natal Province, Republic of South Africa: QAP implemented the first randomized control trial to measure the impact of accreditation in a developing country setting and reports its findings in this Operations Research Results report. The study began in the late 1990s when KwaZulu-Natal (KZN) Province in South Africa had just contracted with the Council for Health Services Accreditation of Southern Africa (COHSASA) to introduce hospital accreditation into KZN public hospitals. COHSASA and the Joint Commission International (JCI) cooperated with QAP to implement the study, and these organizations present commentaries in the ORM airing their positions on the study in particular and hospital accreditation in general. The central issue to the report addresses the extent to which accreditation, known to favorably impact measurable indicators relating to the quality of care, actually improves patient outcomes. While exploring this issue, the report also sheds light on the importance of careful planning and communication in implementing complex research and would serve as a guide to others in undertaking similar efforts.
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The Nicaragua Mother and Baby Friendly Health Units Initiative: Factors Influencing Its Success and Sustainability presents findings on that country's efforts to support breastfeeding. The report cites data from earlier studies and national surveys showing expansion of breastfeeding practices in Nicaragua. The reports credits several factors for this continued growth and sustainability: national laws, leadership by the Ministry of Health, a growing cadre of health professionals who advocate for the principles of breastfeeding, expansion to all health programs, involvement of universities, publicity and educational activities, and quality assurance efforts. Appendices provide Nicaragua's 11 criteria for certification as mother and baby friendly and a summary of self-assessment processes, problems uncovered, and corrective actions.
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La Iniciativa de Unidades de Salud Amigas de la Niñez y la Madre en Nicaragua

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Review of Health Services Accreditation Programs in South Africa: South Africa's healthcare system is still struggling to ensure equal access to quality services for all its citizens. One thrust in this effort is accreditation: This methodology supports service providers in achieving and maintaining quality. Accreditation can have a broad focus, for example, determining whether many of the services a hospital provides are high quality, or it can have a narrow focus, for example ensuring that a hospital's pharmacy meets standards. This brief report describes four different accreditation programs in South Africa: one is nationwide and addresses hospitals; the second accredits privately financed healthcare programs; the third is a provincial program accrediting all public healthcare facilities, and the fourth assesses clinics providing adolescent reproductive health. This operations research study interviewed stakeholders of the South Africa healthcare system to elicit their views of the best possible options for South Africa and of the strengths and weaknesses of the four existing programs. Recommendations favor policies to continue existing accreditation programs and create new ones, regular accreditation/ reaccreditation, the public release of accreditation reports, and other steps to improve healthcare quality.
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Setting up a National Hospital Accreditation Program: The Zambian Experience: Zambia was the first country in sub-Saharan Africa to adopt a national hospital accreditation program. Three years after the launch, in 2000, QAP and Joint Commission Resources, Inc., documented and assessed the milestones, successes, and challenges to the still-growing program. This report includes recommendations for Zambia; in addition, the milestones framework would help other countries learn from Zambia's experience. Milestones included recognizing the need to improve quality, choosing the right accreditation model, setting up the formal structure, developing and testing standards, training surveyors, etc.
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The Zambia Accreditation Program Evaluation report examines whether Zambia's hospital accreditation program improved health outcomes and other indicators. Performed after an accreditation program had been launched in about 40 hospitals, the evaluation examined eight indicators of healthcare quality at hospitals that had and had not been exposed to the accreditation program. The eight evaluation indicators included health outcomes (e.g., death rate within two days of arrival at hospital), downstream indicators of quality (e.g., availability of emergency drugs), and upstream indicators (nurse satisfaction). The evaluation measured whether the accreditation program had had an impact on these outcomes and indicators and found mixed but interesting results. The report is rich in details about what can go right and what can go wrong in such program and concludes that accreditation programs in Africa can have a positive impact on hospital compliance with such programs, especially if the programs provide education, consultation, technical assistance, and a gradual and graduated sequence of steps toward accreditation.
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Client Satisfaction and Participation

Client Communication Behaviors with Healthcare Providers in Indonesia: This 1997-98 study examines client participation (defined as client active communication) during family planning consultations in Indonesia. Culturally acceptable ways for Indonesians to participate in consultations include asking questions, requesting clarification, giving opinions, and expressing concerns. This study showed that five factors encouraged client communication: three on the provider side (information giving, facilitative communication, and expressing negative emotion) and two on the client side (education level and province). The results suggest that a combination of provider training and client education on key communication skills could increase client participation.
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Helping District Teams Measure and Act on Client Satisfaction Data in Niger: This 1997-98 study collected data on client satisfaction with health services in three districts in Niger, testing two different data collection tools (focus groups and exit interviews) and three different data collector types (supervisors from the district where data were being collected, supervisors from a neighboring district, and outside enumerators). After assessing the two tools and data collector types on the basis of validity, feasibility, utility, and cost, the research team found that exit interviews and supervisors from the same district rated highest in terms of validity, cost, feasibility and utility. However, important advantages and disadvantages were found for each tool and method. The report provides examples of the data collection instruments as well as an innovative "rapid" feedback package for client satisfaction measurement. This report will guide district-level managers in measuring and using client satisfaction data.
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Implementing a Client Feedback System to Improve the Quality of NGO Healthcare Services in Peru: Aware that improvements to healthcare services require an understanding of clients' perspectives, QAP investigated six methods for collecting client feedback at two clinics in Chiclayo, Peru, in 1998-99. This report describes the information collected and compares the data collection methods (exit interviews with clients, follow-up visits, focus group discussions, interviews with discontinued clients, and suggestion boxes) whose validity, utility, feasibility, and cost varied considerably. Quality improvements resulting from the study are also described; they included improving the response time to client complaints, sensitizing clinic personnel to clients' concerns, and reducing waiting times.
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Compliance with Standards

Assessing the Functionality of Job Aids in Supporting the Performance of IMCI Providers in Zambia: This report covers research undertaken in 1999-2000 and provides an analysis of the use of job aids in complying with the Integrated Management of Childhood Illness (IMCI) algorithm. The focal job aid was a booklet that guided providers through the algorithm and also had spaces to record a patient's name, temperature, treatment, etc. For the initial assessment, observers watched providers treat children in settings where job aids (a chartbook, recording form, etc.) had been provided. Next, a new job aid (the booklet) was developed on the basis of those observations and interviews with providers. Last, observers watched providers who had available both the original job aids and the new one. The study methodology did not address whether providers who previously did not use a job aid improved their compliance when they started doing so. It did find higher compliance when a job aid was used and that providers believe there are many advantages to using job aids. It also confirmed previous findings that providers hesitate to use job aids in front of caretakers/patients but also found, ironically, that caretakers preferred providers who used aids.
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Bangladesh: NGO and Public Sector Tuberculosis Service Delivery Rapid Assessment Results: The Quality Assurance Project commissioned a rapid assessment of the Bangladesh service delivery system for TB-DOTS, the internationally recommended strategy for tuberculosis control. The assessment was designed to inform the development of a context-specific strategy to ensure the delivery of high-quality TB-DOTS care to achieve sustained detection of 70% of new smear-positive patients and an 85% cure rate. Examining the various aspects of both the Government- and NGO-managed systems, the assessment measured the following elements of the Bangladesh National Tuberculosis Program, of which the USAID-funded NGO Service Delivery Program is also a part: awareness-raising efforts, identification of suspects, case detection, mode of DOTS, cure rate, physical facilities, technical capacity, record keeping, referrals, and facility-to-facility referrals. After a presentation of findings, the report makes recommendations to achieve the targeted case detection and cure rates.
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Comparison of Two Methods for Determining Provider Attendance during Normal Labor and Delivery: Benin, Ecuador, Jamaica, and Rwanda grapples with the problem of imperfect data collection by clinical observers. The observers used two methods to record the attending providers at delivery, resulting in two sets of data that should have matched but did not. The authors present the underlying assumptions and methodology they used to devise the most reliable estimate of the number and type of attending providers. An appendix sets out the mathematical formula used such that other may replicate the methodology.
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The Effectiveness of TB DOTS Supporters in South Africa: This study used qualitative research to examine the effectiveness of lay health workers in implementing directly observed treatment (DOTS) for tuberculosis in South Africa. Responses from focus group discussions and interviews with mostly volunteer DOTS supporters illustrate both the problems and advantages of these programs. The report probes attitudes toward and experiences related to working without pay, females supporting male patients, gangsterism, training, needed skills, and others. While too brief to be a full investigation into all the implications of such a program, this report at a minimum airs and makes recommendations about several issues that might go unanticipated by program managers implementing similar programs. Tools: Consent forms.
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Estudios de maternidad seguraResultados del Competencia del personal calificado para la atención al parto; El ambiente viabilizador para la atención calificada al parto; Demoras en el tratamiento de complicaciones obstétricas dentro de los establecimientos de salud (Análisis de la tercera demora: This report presents the results from of the Quality Assurance Project’s three Safe Motherhood Studies: competence of skilled birth attendants, the enabling environment for skilled attendance at birth, and the causes of the "third delay"the delay in receiving medical attention after a woman arrives at a healthcare facility. The studies included five hospitals: a tertiary care referral hospital in the capital, two secondary care provincial hospitals, and two small district hospitals. (available in Spanish only: 41 pages)

Factors Associated with Adherence to Antiretroviral Therapy in Rwanda: A Multi-site Study: Adherence to antiretroviral therapy (ART) will result in better health outcomes. However, studies investigating such adherence usually examine only part of adherence requirements: They study the number of pills taken, but not whether they were taken in accordance with other requirements, such as taking pills on a schedule and with food requirements. This study, conducted in 2004–2005 in four Rwandan health facilities, found indications that pill combination type was a more important indicator of adherence than the burden of having to take numerous pills. In addition, while 92–98% of study participants reported meeting pill-count requirements, only 69–73% met schedule and food requirements. The report details adherence by treatment type, and the analysis explains associations with such factors as social support and urban versus rural settings. 
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The Impact of QA Methods on Compliance with the Integrated Management of Childhood Illness Algorithm in Niger: Research on the Integrated Management of Childhood Illness (IMCI) shows that it is a scientifically sound way to treat sick children, but ways to ensure that it is implemented properly are lacking. This 1997-98 study examined and compared three implementation approaches: structured feedback of performance data, structured feedback of performance data where quality improvement (QI) teams were in place, and the formal World Health Organization training in districts with QI teams. The report details the impact of each intervention, noting that sustaining performance is problematical under any intervention. The cost of IIMCI training was four times that of performance feedback.
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The Impact of Self-Assessment with Peer Feedback on Health Provider Performance in Mali: This study sought to better understand how to sustain provider compliance with standards, using local (Mali) standards (on care for fever and structural quality). The intervention had two parts: a self-assessment instrument that providers used weekly to assess their performance with a feverish client and a review of that performance by a colleague who had observed the consultation. The study found that when used regularly, such an intervention can have a significant effect on compliance. It determined the cost of the intervention to be US$250 for 36 providers; some providers felt the three-month intervention was too long.
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Improving the Management of Obstetric Emergencies in Uganda through Case Management Maps: Case management maps (CMMs) are a type of job aid: a sheet of paper with information that guides healthcare providers in treating patients. Each patient has his or her own condition-related CMM, which is maintained in the patients chart or on the wall near the patients hospital bed to inform providers of the treatment protocol, what treatment was provided when and by whom, what to do should a critical event occur, etc. This report describes a study that implemented two CMMs that were introduced about a year apart in a 500-bed hospital where such job aids had not previously been used. Planning and implementing the CMMs, the results from their implementation, and recommendations for further use of CMMs in developing countries are discussed. Appendices include the CMMs; one is for pregnancy-induced hypertensive disorders and the other is for postpartum hemorrhage.
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Increasing Compliance with Maternal and Child Health Standards: This summary presents the results of a study conducted to determine the effects of hospital QA interventions on compliance with clinical standards, availability of essential drugs, client satisfaction, and utilization. The study, conducted with four intervention and four control hospitals, found that after 12 months, the QA interventions produced rapid increases in compliance with clinical standards in the intervention hospitals as compared with the control group. The citation for the full report is: Hermida J and Robalino ME. 2002. Increasing compliance with maternal and child care quality standards in Ecuador. International Journal for Quality in Health Care 14 (Suppl 1): 25:34. The table of contents and article abstracts can be viewed online at: http://intqhc.oxfordjournals.org/cgi/content/abstract/14/suppl_1/25
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Kenya: Assessment of Health Workforce Competency and Facility Readiness to Provide Quality Maternal Health Services: This report presents the findings of a 2006 assessment of three types of facilities that provide maternal and newborn care in six representative districts in Kenya. Providers were given a 50-question knowledge test, and their skills were assessed as they performed five delivery and neonatal procedures on anatomical models: active management of the third stage of labor (AMTSL), manual removal of the placenta, bimanual uterine compression, immediate newborn care, and neonatal resuscitation with ambu bag. Facilities were assessed in the areas of human resources, infrastructure, care standards, and drugs and equipment. The report concludes that health provider competency at performing basic, life-saving skills was quite low, and the tendency to refer patients with complications was all too common despite weak referral and counter-referral mechanisms. The findings indicate a need for strengthening, in particular, hand washing practices and bimanual uterine compression skills. Recommended interventions to improve poor skills include competency-based training, supportive supervision, and coaching. The report’s findings also call attention to the need to improve infrastructure at a basic level and ensure availability of all necessary supplies and equipment to ensure safe deliveries in health facilities. Appendices provide the knowledge test and answer key, observation instruments for the skill assessments, the facility assessment instrument, and a list of equipment and supplies needed to perform the entire assessment.  Download report.  43 pages. 

The Niger QAP/BASICS Joint Project: An Evaluation of QA Activities Two Years Later: QAP provided technical and operational support to basic health services in Nigers department of Tahoua in the 1990s; success was evaluated in 1998. The program improved healthcare quality through training, supervision, meetings, operations research, and the provision of some equipment. This study assessed the continuation of quality assurance (QA) two years after program cessation and after political events in Niger, including a military coup, significantly influenced the programs sustainability. The report finds continuation of some QA activities, particularly supervisory visits, but others fared less well. Sustainability of the visits is credited to their being well organized and comprehensive, their availing trained supervisors, and their undergoing continuous improvement. Study instruments are provided in the appendix.
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Quality of Obstetric Care Observed in 14 Hospitals in Benin, Jamaica, and Rwanda discusses care provided to 245 women during labor, delivery, and immediate postpartum and their newborns during immediate postpartum. The quality of care for different tasks (e.g., monitoring fetal heart rate) is presented by country, by hospital type, and overall. The report details performance on recommended tasks and should inform program managers and providers in finding similar weaknesses in their own care delivery systems. Report includes 21 data tables and the data collection instrument for observations.
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Safe Motherhood StudiesResults from Benin: Competency of Skilled Birth Attendants, The Enabling Environment for Skilled Attendance at Delivery, In-Hospital Delays in Obstetric Care (Documenting the Third Delay): Through its Safe Motherhood Research Program, the Quality Assurance Project carried out three studies to explore issues regarding competence of skilled birth attendants, the elements that contribute to an enabling environment and the causes of what is commonly known as the third delaythe delay in receiving medical attention after a woman arrives at a healthcare facility in countries with high maternal mortality ratios. The first study examined the competency of skilled birth attendants (SBAs). The second measured SBA performance and the relative contribution to performance of different enabling factors in the work environment. The last study examined causes of in-facility delays in receiving obstetric care. All three studies were carried out between September 2001 and July 2002 in Benin, , Jamaica, and Rwanda. This report presents the results from Benin. The Benin studies included five hospitals: a tertiary care referral hospital with an active maternity department, two secondary care hospitals, and two smaller district hospitals.
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Safe Motherhood StudiesResults from Jamaica: Competency of Skilled Birth Attendants; The Enabling Environment for Skilled Attendance at Delivery; In-Hospital Delays in Obstetric Care (Documenting the Third Delay): This report presents the results from Jamaica for the of the Quality Assurance Project's three Safe Motherhood Studies: competence of skilled birth attendants, the enabling environment for skilled attendance at birth, and the causes of the "third delay"the delay the delay in receiving medical attention after a woman arrives at a healthcare facility. The Jamaica studies included four hospitals: a referral facility in Kingston, two regional hospitals, and one district hospital. Download report (33 pages)

Safe Motherhood StudiesResults from Rwanda: Competency of Skilled Birth Attendants; The Enabling Environment for Skilled Attendance at Delivery; In-Hospital Delays in Obstetric Care (Documenting the Third Delay): This report presents the results from Rwanda for the of the Quality Assurance Project's three Safe Motherhood Studies: competence of skilled birth attendants, the enabling environment for skilled attendance at birth, and the causes of the "third delay"the delay in receiving medical attention after a woman arrives at a healthcare facility. The Rwanda study focused on an urban referral (tertiary care) hospital with an active maternity department, two mid-sized referral (secondary care) hospitals, and four health centers. Download report (31 pages)

Safe Motherhood StudiesTimeliness of In-Hospital Care for Treating Obstetric Emergencies: Results from Benin, , Jamaica, and Rwanda presents data on in-hospital care for childbirth and obstetrical emergencies in 14 hospitals. Observations included 859 women arriving for obstetric care, and audits included 383 obstetric emergencies. This report examines intervals between critical events (e.g. arrival at hospital, initial evaluation by a professional, diagnosis, order of treatment, and administration of treatment) and presents experts judgements on whether delays occurred and, if so, when and why. Data are disaggregated by country, hospital type, diagnosis, type of delay, etc. Report includes record review algorithm and 24 data tables.
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Treating Tuberculosis in the Private Sector: Cambodia: The Quality Assurance Project undertook a national assessment of private sector tuberculosis (TB) services in Cambodia to improve understanding of private sector practices and the sector's willingness to participate in efforts to improve TB services. Over 500 respondents, including doctors, pharmacists, drug sellers, and TB patients, participated. In addition, mystery shoppers visited private pharmacists and drug sellers so that the surveyed groups' reports could be compared to actual experiences. The survey uncovered many aspects of private sector TB services that are undermining the Cambodian Government's efforts to increase detection and cure rates. Recommendations focus on bringing the private sector into the National TB Program so that all patients seeking TB care will receive quality services.
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Using Problem-Solving Teams to Improve Compliance with IMCI Guidelines in Kenya: The research described in this report investigated whether facility-based teams that had been trained and coached to develop and implement improvements in performance of the Integrated Management of Childhood Illness (IMCI) algorithm through problem-solving teams would improve case management. The study compared 21 facilities with teams and 14 without, all in rural facilities in Kenya. The teams developed nine different types of solutions to problems they identified at their facilities: The most frequent solutions included procuring more IMCI drugs, introducing a clocking-in register, and initiating on-the-job training.
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Cost-Effectiveness of QA

Application of Activity-Based Costing (ABC) in a Peruvian NGO Healthcare System: This paper describes the application of activity-based costing (ABC) to calculate unit costs for a healthcare organization, showing how these calculations yield information for improving the efficiency and quality of healthcare services. Traditional costing allocates overhead and other support costs on the basis of units of production. ABC may result in more accurate estimates of real unit costs: it assigns overhead and other support costs through the principal activities performed, linking indirect costs to services/products through time allocation and other tracing methods. Performed in 1997-98, the study found that (a) ABC was successfully implemented in this developing country setting, (b) ABC analysis can guide pricing and identify needed subsidy levels, and (c) ABC can open opportunities for cost savings through quality improvement of service delivery.
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Assessing the Economic Impact of the New System of Care for Arterial Hypertension in Tula Oblast, Russia: This report provides an analysis of the changes to the costs of a system that was redesigned using quality improvement. Changes to the system involved identifying people with arterial hypertension (AH) so that they could lead healthier lifestyles and receive treatment at the primary care level. This resulted in fewer AH emergencies and shorter hospital stays. This report shows the sources of cost information and finds that decreases in the cost of intensive care exceeded increases in the costs of primary care.
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Compliance, Workload, and the Cost of Using the Integrated Management of Childhood Illness Algorithm in Niger: This study examines the relationship between IMCI compliance and three cost issues: the length of client-provider consultations, treatment drugs, and workload. The setting was 26 health clinics in Niger, the only developing country setting where QA was implemented before IMCI. Where other studies have found a link between IMCI compliance and higher costs, this study of 211 cases of childhood illness found no such association.
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Improving the Quality of Care for Women with Pregnancy-Induced Hypertension Reduces Costs in Tver, Russia: The Quality Assurance Project/Russia demonstration project in 1998 in Tver Oblast improved the quality of care for women with pregnancy-induced hypertension (PIH). Central to the effort was the development and introduction of evidence-based clinical guidelines for PIH management that treated PIH early and rationalized admission and drug-use criteria. This cost study measured PIH-related direct costs for inpatient and outpatient cases. Total direct inpatient-related costs decreased by 86 percent, and direct per-inpatient costs decreased 41 percent, with substantial decreases at all severity levels following the introduction of the new guidelines. Findings suggest that outpatient care costs potentially associated with PIH care also dropped, but an inability to separate PIH and regular antenatal costs made it difficult to pinpoint the decrease.
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Measuring the Cost of Inefficient Use of Laboratory Resources: This report addresses the challenges of ensuring quality healthcare services while containing costs, QAP developed and tested measurement methodologies for seven separate sources of economic waste in hospital laboratories: unneeded tests, unclaimed tests, resource use inefficiency, staffing inefficiency, expired reagents, poor quality control, and inefficient procurement. Three ian hospitals of differing sizes served as the setting for this study. Short turnaround was one aim of the study, so it relied on existing records, observations of the labs, staff interviews, and expert clinical opinion. "Waste" was determined using standards set by ad hoc committees at each hospital. The report details the usability, validity, and usefulness of each methodology by source of waste. For example, waste through expired reagents was examined by an audit, which revealed that no hospital had a system for discarding expired reagents, that hoarding seemed common, and that measuring reagent waste on a short?turnaround basis is problematical because the shelf-life of the reagents is longer than the turnaround period. Each data source is also discussed in terms of its usefulness in assessing economic waste in hospital laboratories. The conclusion highlights the need to improve each methodology and suggests ways to do so.
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Health Workforce

Evaluation of Knowledge, Attitudes, and Practices of Health Care Providers toward HIV-positive Patients in Tanzania: This report presents an evaluation of the prevalence and manifestations of stigma and discrimination by Tanzanian health care providers toward people with HIV/AIDS. QAP conducted interviews with providers in three public hospitals in Dar es Salaam to assess stigma and discrimination and their associations with providers’ HIV/AIDS knowledge, their perceived risk of infection, their willingness to care for people with HIV/AIDS, and the availability of protective wear. Most providers expressed at least one negative attitude, such as blame for infection. Discriminatory practices were rare but included selective use of universal precautions, denial of services, substandard treatment, and failure to respect patients’ rights. HIV knowledge was inversely associated with negative attitudes, and providers who feared HIV infection through casual contact had significantly more negative attitudes. In addition, stigma was associated with providers’ selective use of universal precautions.  However, these providers willingly provide care to HIV/AIDS patients. The study concludes that HIV-related stigma and discrimination may be attributable to poor HIV related knowledge and fear of infection. It recommends communicative forums and training to allay provider fears and improve understanding of HIV and infection methods. 
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HIV/AIDS-Related Stigma, Fear, and Discriminatory Practices among Healthcare Providers in Rwanda: In response to concerns that stigma and discrimination pose barriers to access to healthcare services for patients with HIV or AIDS, the Quality Assurance Project surveyed 110 healthcare providers in six health facilities in Kenya in late 2003–early 2004. Structured interviews assessed provider beliefs, attitudes, practices, and fears toward providing care to these patients. Findings indicate that all providers expressed negative attitudes and fear, and most reported being aware of discriminatory practices by providers and facilities toward these patients. The report concludes that as long as providers feel unsafe in providing services to these patients, discrimination will persist. The report discusses the implication of these fidings for stigma reduction strategies to ensure high quality health services for people with HIV/AIDS. Appendices provide informed consent text and the four instruments used for the interviews. Download report. 32 pages.

Rwanda Human Resources Assessment for HIV/AIDS Services Scale-upPhase 1 Report: National Human Resources Assessment: This report presents findings from Phase 1 of an assessment of the human resources implications of HIV/AIDS services scale-up in Rwanda. Services covered include voluntary counseling and testing, prevention of mother-to-child transmission, and care and treatment, including lab services and drug dispensing. It reports the number and types of staff employed at public and private healthcare sites, estimates the number providing HIV/AIDS services, and identifies employment practices that could facilitate or hinder the human resources scale-up. In addition to providing statistics relative to the healthcare workforce, the report discusses such issues as user fees and salary disparities. Download report (10 pages)

Rwanda Human Resources Assessment for HIV/AIDS Services Scale-upPhase 2 Report: Sample Site Data Collection and Analysis: Based on the findings in the Phase 1 report, this report reviews Rwanda's healthcare staffing, documents practices and levels of effort in providing HIV/AIDS services, and calculates staffing needs for scale-up. It also discusses such issues as training, management, supervision, job satisfaction, and staff motivation and incentives.
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Rwanda Human Resources Assessment for HIV/AIDS Services Scale-up Phase 3 Report: Staffing Implications and Scenarios for HIV/AIDS Services Scale-up: Based on the findings in the Phase 1 and 2 reports, this report estimates how many full-time equivalent staff will be needed to meet various scenarios of scale-up targets and associated costs. It also addresses such issues as varying prevalence rates and their implications for services uptake, the need to balance demand and capacity, and options for using various cadres to provide services beyond their current responsibilities.
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Rwanda Human Resources Assessment for HIV/AIDS Services Scale-up: Summary Report examines the workforce issues surrounding HIV/AIDS service delivery. At the request of the Government of Rwanda, data were collected on current health sector staffing and from 20 public and private facilities of various sizes and characteristics on the time required to provide HIV/AIDS services and the quality of those services. The report presents data relative to the numbers of clients needing different types of HIV/AIDS services, providers' degree of compliance with service delivery standards, and the time it takes to provide services. Staffing scenarios are projected to estimate how many staff would be required to meet targets, and from them, costs are projected. This report is a summary of the full study report, which is presented as three phase reports. Download report (46 pages)

The Zambia HIV/AIDS Workforce Study: Preparing for Scale-up: Anticipating massive scale-up of its HIV Voluntary Counseling and Testing (VCT), prevention of mother-to-child transmission (P-MTCT), and antiretroviral therapy (ART) services with a Global Fund award, the Central Board of Health of Zambia commissioned this study of the human resource implications of its intended national expansion of current HIV/AIDS services. The study, conducted by QAP subcontractor Initiatives Inc. in early 2003, collected data at 16 government, NGO, and private, for-profit sites across Zambia that provide VCT, P-MTCT, and ART services. The research measured the time required to perform counseling, lab tests, drug dispensing, etc. for each of the three types of services. Performance was also compared to national standards to account for gaps in services that should be corrected. The report provides projections for national scale-up of counseling, testing, and therapy across three HIV-prevalence scenarios and provides implications for the training that will be necessary to achieve the necessary workforce levels. The report includes extensive tables and 10 data collection instruments that illustrate the study methodology. Its approach and results will be of particular interest to other countries grappling with the human resource implications of scaling up HIV/AIDS services.
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Zambia Performance-based Incentives Pilot Study evaluates an intervention to raise healthcare provider morale and retention. Two different incentivescash and a trophy, awarded to facilities rather than individualswere tested in two districts. The program was implemented district-wide. Health centers and other small health facilities competed for the awards and were scored on the basis of management system indicators. Interviews with staff in both districts measured the effect of the awards on staff motivation and satisfaction. The study echoed other research by documenting the importance of leadership and management to performance-based incentives programs and the need for fairness and transparency in the implementation of such programs. It found that staff motivation improved substantially with these small gestures of support and that district managers believed the program supported their work. Download report (40 pages)

Improving Training and Supervision

A Comparison of Computer-Based and Standard Training in the Integrated Management of Childhood Illness in Uganda: Facilitator-led training of 20 healthcare providers in IMCI requires 11 days of lectures/practice and 6 facilitators, while the QA Project's computer-based training requires 9 days and 4 facilitators. This study compared the cost-effectiveness of the two methods and found that both courses had equal effects on participants' knowledge and skills, and retention after three to four months. The computer course was about 25 percent less expensive, excluding the cost of developing the software and for the computers used in the training.
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Evaluation of an IMCI Computer-based Training Course in Kenya: The Quality Assurance Project (QAP) has developed and twice tested a computer-based version of the Integrated Management of Childhood Illness (IMCI) training course. Earlier testing had shown that the computer-based training (CBT), which takes six days, was as effective as the 11-day training traditionally used to teach healthcare providers to use IMCI. This report describes more recent testing of the CBT, which is available on CD-ROM. The two training programs are equally effective in knowledge transfer, as demonstrated here through a knowledge test and observed performance with two simulated, standardized cases of childhood illness. Budgeted costs were $230 or 29% less per trainee for the computer-based training, largely because of the reduction in the number of days committed to training.
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Improving Provider-Client Communication: Reinforcing IPC/C Training in Indonesia with Self-Assessment and Peer Review: This study tested two low-cost alternatives to supervision-self-assessment and peer review-that may reinforce providers' skills after training, in this case training in interpersonal communication and counseling (IPC/C). There were three study groups: the control group received no reinforcement after training, a "self-assessment" (SA) group performed SA exercises for 16 weeks after training, and a SA and peer review group also performed SA exercises for 16 weeks and met in small groups to peer review and guide each other in their efforts to improve their IPC/C skills. These reinforcement strategies taught providers how to work more efficiently so that they could shorten consultations yet provide high quality interactions with clients. An analysis of the cost-effectiveness of each intervention is included.
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Participatory Supervision with Provider Self-Assessment Improves Doctor-Patient Communication in Rural Mexico: In this setting, physicians were already making site visits to clinics to monitor technical standards of care. An intervention was designed to reinforce doctors' interpersonal communication (IPC) training. Under the intervention, doctors received IPC job aids, self-assessment forms, and tape recorders. They taped themselves during consultations and assessed their skills from the recordings, using the forms and in consultation with their supervisors. The self-assessment form and the supervisor assessment form were modified to be reproduced in this report; for a full discussion of the method used to measure communication behaviors, see also the Operations Research Report titled "Improving Provider-Client Communication: Reinforcing IPC/C Training in Indonesia with Self-Assessment and Peer Review."
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The Quality of Supervisor-Provider Interactions in Zimbabwe: This report describes a study measuring the quality of supervisor-provider interactions and includes the instruments developed for recording information from supervisory interactions. The study observed and taped supervisory visits, logged all supervisory activities, interviewed supervisors and providers, and collected supervision checklists that may have been in use at the healthcare site. Results detail what the supervisors' strengths and weaknesses were; recommendations for the Ministry of Health that would improve supervision are included. Download report (16 pages)
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Quality Improvement and Redesign

Developing Job Aids to Increase Adherence to an Antibiotic Regimen in Children with Pneumonia in Niger: Poor patient adherence to drug regimens has been identified as a factor linked to antimicrobial resistance (AMR). This report explains how quality assurance methods were applied to the problem of AMR to increase patient adherence to the recommended regimen for cotrimoxazole for childhood pneumonia. The project started with research to determine what type of client-based job aids would be most appropriate at the study site, what messages should be conveyed by the job aids, and whether an additional intervention was needed. Next, a workshop was held and focused largely on behavior change communications. Workshop participants all took different roles in the development of the job aids. Images of the final job aids (a poster and counseling card for healthcare providers and a pill envelope for caretakers) are provided, as are the research instruments.
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The Impact of a Programme to Prevent Mother-to-Child Transmission of HIV: Disease Transmission and Health-Seeking Behaviour among HIV-Positive Mother-Child Pairs in Jamaica: This study examined the practices of women in Jamaica who had been found HIV-positive during antenatal visits and who had participated in a pilot program to prevent mother-to-child transmission of HIV/AIDS. The study measured the women's knowledge, attitudes, and practices relating to the prevention of transmission, stigma, and related issues; tested infants of consenting mothers for HIV status; and observed providers in selected clinics to identify program areas needing improvement. Although the small sample size did not show any statistical difference in disease transmission for women who did or did not take nevirapine, the study did find that women who did not breast feed were less likely to transmit the virus to their infants (p< 0.001).
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Improving Adherence to Cotrimoxazole for the Treatment of Childhood Pneumonia in Niger: QAP has tested various ways to improve adherence to treatment regimens, including developing job aids for providers and/or caretakers. This 2001-02 study examined the effect on adherence when both providers and caretakers used job aids. Providers (all nurses) had a counseling card and a poster with drawings showing how to crush, administer, and store antibiotic pills; caretakers were given pill envelopes with the same drawings. The research design was quasi-experimental with geographically separate program and control groups. Nurse adherence, caretaker adherence, and overall adherence were analyzed and are reported in this report. A significant finding was that while highly trained nurses didn't have much room for improvement in their adherence practices, less highly trained nurses made great strides.
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Neighbor-to-Neighbor Education to Improve Malaria Treatment in Households in Bungoma District, Kenya: Spreading the word on appropriate use of anti-malarials cost about $US 83 per household under the intervention described in this report. QAP and the African Medical Research and Education Foundation trained extension health workers for one day on the neighbor-to-neighbor approach and distributed multiple copies of two illustrated brochures on proper malaria treatment to those workers. They led a pyramid distribution of the brochures in 112 villages and organized contests featuring songs, dramas, and poems to promote effective anti-malarial drugs. In six weeks, the intervention had reached 53% of households in the intervention area. Respondents in the intervention area were more likely to know the MOH-recommended anti-malarial drugs and to report intention to use them. The intervention was particularly influential on people with less education.
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Quality Improvement Teams in Morocco: An Evaluation of Functionality and Success: This report describes research from 1999-2000 addressing two quality improvement (QI) issues: What are the factors that lead to successful QI teams, and What is the cost of establishing and supporting QI teams? The research was a cross-sectional evaluation of team "functionality"the degree to which teams complete QI work according to a "standard" QI methodology-and the factors affecting such functionality. Investigators found that the teams were well versed in the QI methodology, and team leaders and members showed high facility with QI terms and tools and were highly motivated in their QI work despite resource constraints. With regard to overall functionality, the teams did quite well in identifying and analyzing problems, but they scored higher in completing the QI steps than in developing solutions. Getting results was shown to be related to following the QI methodology but not to resources consumed, team climate and satisfaction, and coach rating by the team.
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Redesigning Hospital Documentation Systems to Improve the Quality of Obstetric Patient Records in Ecuador: Quality documentation in healthcare facilities is important for both patient care and monitoring and improving systems needing quality improvements. This research applied a systematic and participatory redesign methodology to successfully improve the completeness, legibility, and coherence of medical records. The report describes the redesign process sufficiently to guide facility policymakers and managers in improving their own documentation systems.
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Testing a PMTCT Infant-feeding Counseling Program in Tanzania:  This report describes the results of an assessment of job aids and take-home materials that nurse-counselors used in helping expectant mothers select an infant-feeding method.  In countries with high rates of HIV/AIDS, such as Tanzania, preventing HIV transmission while at the same time protecting the infant from other potentially fatal conditions, such as diarrhea and malnutrition, is difficult.  The tested job aids and take-home materials, available elsewhere on this website, included longer materials that were retained by counselors and brief brochures that counselors used in discussion with mothers and then gave to mothers to keep.  By comparing the experiences, knowledge, and behaviors of mothers who were and were not counseled with the aids, the study found that those who used them were better informed and more able to sustain their chosen infant-feeding practices.  The report also recommends further consideration of international criteria relating to infant feeding in resource-restrained settings.
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Vendor-to-Vendor Education to Improve Malaria Treatment by Drug Outlets in Kenya: Private drug outlets are the main source of malaria drugs in endemic areas, but these outlets frequently give incorrect information on drug use, including dosing. The World Health Organization has included the private sector in its Roll Back Malaria strategy, but notes that it is notoriously difficult to change private sector practices without burdening governments. QAP teamed up with the Bungoma (Kenya) District Health Management Team and African Medical and Research Foundation in 2000 to test an innovative, low-cost approach for improving the prescribing practices of these outlets. They trained wholesale vendors and gave them posters so they could educate and give posters to drug retailers. Mystery shoppers helped researchers determine the effectiveness of the vender-to-vendor education concept: Outlets that received the posters had better malaria knowledge and prescribing practices than those that did not. Information on the reach and cost of the effort is included in the report.
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