Abstract
BackgroundAccess to health services in Afghanistan has expanded in the last decade; however, gaps in care quality and outcomes of care remain a challenge. Recognizing these gaps, in 2009 the USAID Health Care Improvement Project (HCI) began assisting the Ministry of Public Health (MoPH) in Afghanistan to improve the quality of health services. Though eventually scaled up to nine provinces, in 2009 the MoPH and HCI began developing and testing a facility-based, scalable model of maternal and newborn interventions in health facilities in Kunduz and Balkh provinces and in several large public and private hospitals in Kabul.Case descriptionTo address these issues, the MoPH and HCI applied the collaborative improvement approach, which links the efforts of multiple teams focused on making improvements in the same area of care to achieve the same aims. As demonstration sites, two provincial level quality improvement teams (QITs) were established in Kunduz and Balkh provinces that, in turn, supported 25 facility-level QITs chosen by purposive sampling. In addition, three government maternity hospitals and three private hospitals in Kabul were selected by the MoPH to participate in a demonstration hospital collaborative. Measurable gains were achieved in these demonstration sites for use of the partograph, compliance with antenatal care counseling, vaginal births for which all three elements of active management of the third stage of labor were performed, and compliance with newborn and postnatal care standards.Discussion and evaluationQuality of care can be significantly improved by engaging teams of frontline workers to identify problems and find local solutions for those problems. Based on the results achieved in Kunduz, Balkh, and Kabul, the collaborative improvement work was expanded from 2010–2012 to seven more provinces. The results achieved on the ground also led the MoPH to establish a unit for quality and a national health care quality improvement strategy for Afghanistan.ConclusionsAfghanistan demonstrates that even in fragile states, measurable improvements in actual patient care at the frontlines of service delivery can be achieved while systematically building capacity at all levels of the health system through national leadership and policy making.
Highlights
Access to health services in Afghanistan has expanded in the last decade; gaps in care quality and outcomes of care remain a challenge
Recognizing these gaps, in 2004 the Ministry of Public Health (MoPH) began a series of initiatives to improve health care quality, increasing the number of partners working on health care in the country
One such initiative began in 2008, when the United States Agency for International Development (USAID) Mission in Afghanistan requested that the USAID Health Care Improvement Project (HCI) initiate assistance to the MoPH and implementing partners to help them improve the quality of health services nationwide
Summary
The last ten years have shown increased interest and recognition that human resource factors, such as the roles and responsibilities of frontline health workers, are central to improving health [8]. Implementation of the facility-level collaborative did not come without its challenges These included: high turnover of health facility staff in provinces; limited previous exposure to and understanding of basic improvement concepts among health facility staff, provincial public health officers, and frontline health workers; initial low motivation and commitment of health providers for the implementation of quality improvement efforts resulting from previous working relationships where they were not engaged and felt that they had no control over the problems their facilities faced; political insecurity in most of the provinces where HCI worked; shortage of essential supplies; lack of proper infrastructure for some health care facilities, including shortage of clean water, electricity, toilets and incinerators; and delay in salary payments for health care workers. This article opens up the opportunity for future, more robust study designs using control groups or through enabling health information systems to collect data on the outcomes of interest, where logistically and ethically feasible
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