USAID ASSIST Project Semi-Annual Performance Monitoring Report FY18

University Research Co., LLC (URC) and its partners have completed 5.5 years of implementation of the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. This report is the eleventh Semi-Annual Performance Monitoring Report for ASSIST, summarizing the project’s accomplishments and results during the first two quarters (Q1-2) of Fiscal Year 2018 (FY18).  In late September 2017, the project was awarded a two-year costed extension with additional funding for Zika-related activities.  No further funding was provided for non-Zika work.  The project’s FY18 work plan thus focuses mainly on Zika-related support in eight countries and completion of previously funded work in other countries.

Overall goals
The USAID ASSIST Project fosters improvements in a range of health care processes through the application of modern improvement methods by host country providers and managers in USAID-assisted countries. The project’s central purpose is to build the capacity of host country health and social service systems to improve the effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the services they provide. In addition to supporting the implementation of improvement strategies, the project seeks to generate new knowledge to increase the effectiveness and efficiency of applying improvement methods in low- and middle-income countries.
USAID ASSIST country programs align with the goals of United States Government’s global initiatives and policies, including preventing child and maternal deaths, achieving HIV epidemic control, combating other public health threats, protecting life, and addressing gender inequalities.

Where we work
During the first half of FY18, USAID ASSIST provided technical support in 23 countries through field and core funding. USAID Mission funds supported work in nine countries: Cambodia, Côte d’Ivoire, India, Indonesia, Lesotho, Mali, Swaziland, Tanzania, and Uganda. USAID core funds from the Office of HIV/AIDS supported activities in seven countries: Kenya, Lesotho, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe.  Funds for Neglected Tropical Diseases supported improvement work to combat the Zika virus in the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Nicaragua, Paraguay, and Peru.  USAID cross-bureau-funded activities, through the Office of Health Systems, supported malaria prevention activities in Malawi and global and regional initiatives that contribute to local and global learning in improvement.

FY18 Q1-2 accomplishments and results:

  • Improvement in key indicators: As discussed in this report, ASSIST-supported programs demonstrated improved care and outcomes for a range of services, including antenatal and postnatal care, essential obstetric and newborn care, screening of pregnant women and newborns for Zika-related signs and symptoms, Zika care and support, PMTCT, and HIV prevention.
  • Research and evaluation studies: At of the end of the reporting period, the project had 29 research studies in planning, underway or completed in 14 countries. Three are multi-country studies.
  • Promoting the use of improvement methods: During the reporting period, project staff published nine peer-reviewed articles; seven case studies; four technical and research reports; and 10 guides, tools, and job aids. ASSIST staff led six sessions and made eight oral presentations at six regional and international conferences. ASSIST’s work continued to be promoted through the project’s website and social media engagement, with some 27,867 visitors viewing 61,572 pages within the ASSIST Knowledge Portal during the past two quarters.

Improving PMTCT in Kenya

In 2013, the USAID Applying Science to strengthen and Improve Systems (ASSIST) project supported the National AIDS and STI Control Program (NASCOP) to launch the Partnership for HIV Free Survival (PHFS) initiative in Kenya to apply quality improvement (QI) to drive the national elimination of mother to child transmission of HIV (eMTCT) strategic plan 2012-2015. PHFS mainly focuses on a) ensuring that all mother-infant pairs know their HIV status, b) are retained in care, c) are optimally protected with antiretroviral treatment (ARV) and d) offered nutritional assessment, counselling and support regularly. The aim of PHFS is to reduce mother-to-child transmission of HIV to less than 5% by 2015 by scaling up the application of quality improvement approaches in all PMTCT sites country wide. The use of quality improvement technics was aimed at improving retention in care of mother baby pairs and ensuring that the quality of care given ahead to the set county aligns with eMTCT guidelines.

This document details the experience of ASSIST in Kenya addressing PMTCT, provides guidance to county level actors based on that experience, and case studies of how improvements were achieved in specific facilities.

National Psychosocial Support Guidelines for Orphans and Vulnerable Children in Kenya

These guidelines were developed for use by front line child service providers to streamline psychosocial support services for children. The guidelines provide guidance for supporting caregivers, general guidance for children of all ages, and specific guidance by age range: 0-5, 6-13, and 14-18. An implementation framework is also included.

Improving Care for Orphans and Vulnerable Children and Families: Experiences from implementation in Kenya

This is a compilation of products created with support from the USAID Applying Science to Strengthen and Improve Systems project (ASSIST) in Kenya based on the experience of applying quality improvement methods to improve quality of services for orphans and vulnerable children. This project was implemented between 2013 to September 2017.

This compilation of products is intended for implementing partners (IPs) providing services and/or providing support to service providers of vulnerable children in Kenya. The documents within are intended to guide IPs in mainstreaming and improving quality of service delivery for orphans and vulnerable children. The experiences are drawn from implementations by local organizations including Community Based Organizations (CBOs), Faith Based Organizations (FBOs) and local NGOs.  Included in this package are the following:

  1. Strengthening the Child Protection system: Linking National, County and Community. This document describes the process undertaken by the Department of Children’s Services (DCS) to reform the national child protection systems and service delivery within DCS. It can also be accessed here:
  2. Change Package for Quality Improvement in Orphans and Vulnerable Children Programmes in Kenya. This change package describes the development and dissemination of the quality standards for vulnerable children in Kenya and the process of using QI methods at the point of service delivery to improve care for vulnerable children. This change package includes how-to guidance to improve care across all 8 service areas based on the experience of QI teams piloting the standards. The change package is also available here:
  3. Minimum Service Standards for Orphans and Vulnerable Children in Kenya: Job Aid Booklet. This simple, illustrated job aid was designed for use by community volunteers providing services to vulnerable children. Aligned with the national minimum standards, this booklet is simplified for easy use at the local level in Kenya. The job aid can also be accessed here:
  4. National Psychosocial Support Guidelines for Orphans and Vulnerable Children in Kenya. These guidelines were developed for use by front line child service providers to streamline psychosocial support services for children. The guidelines provide guidance for supporting caregivers, general guidance for children of all ages, and specific guidance by age range: 0-5, 6-13, and 14-18. An implementation framework is also included.
  5. Improving the Lives of Vulnerable Children in Kenya: Experiences from implementing quality service standards. This compilation of case studies highlights experiences, achievements, and personal stories from QI teams and IPs implementing QI to improve services for vulnerable children. It can also be accessed here:  
  6. Videos and blogs: Several videos and blogs further describing specific interventions and achievements are accessible online for further learning and inspiration:


Khunyangu Sub County Hospital Spread Rational Use of ACTs at Bumala B, in Western Kenya

Khunyangu Sub-County Hospital is one of the seven high volume hospitals in Busia County, in Western Kenya. It started implementing quality improvement (QI) in June 2014 when the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project introduced its work in Busia County. The hospital experienced Artemesinin Combination Therapy (ACT) stock outs due to irrational dispensing of Artemether-Lumefantrine (ALs). There were no stocks of ACTs in March 2014 prompting a sub county redistribution in April 2014.

In May 2014, ACTs issued were three times more than the number of confirmed cases. ASSIST introduced QI in the facility and the county in June 2014. Employing a range of QI tools and techniques, the facility was able to eliminate irrationally issued ACTs, translating to approximately 7 months of ACTs saved by January 2015. In the months that followed, the team embarked on ensuring good commodity practices with available ACT dose bands securing their stocks further. They began involving other facilities in the sub-county during sub-county continuous medical education (CME) sessions, Bumala B being one of them.

In February 2016, the coach at Khunyangu selected a coach in Bumala B and a Work Improvement Team (WIT). The coach from Khunyangu helped the WIT at Bumala B implement the changes they had tried in Khunyangu to help secure their ACT and follow through on the test-treat-track (3T) model. ACT doses issued in Bumala B have since dropped from a median of 126% to 100%. Bumala B continues rationally using ACTs.

Improving Uptake of Intermittent Preventive Therapy in Pregnancy (IPTp) at Rachuonyo Sub County Hospital in Homa Bay County

The use of Sulfadoxine Pyrimethamine (SP), commonly known as fansider in pregnant women without malaria has been shown to provide requisite protection against the disease in malaria endemic regions. A dose of SP is given to women at 16 weeks’ gestation, four weeks apart as a directly observed therapy during antenatal clinic (ANC). Greater therapeutic benefits are realized with more intermittent preventive treatment in pregnancy (IPTp) doses. In Kenya, momentum is gaining towards pregnant women receiving three or more doses of IPTp. Rachuonyo Sub County Hospital formed a quality improvement team in November 2016. Following a brainstorming and multi-voting exercise, they settled on improving IPTp uptake. A baseline assessment was done, followed by process mapping, root cause analysis, and development of change ideas to address poor IPTp uptake. Deming’s Plan–Do–Study–Act (PDSA) cycle was followed during implementation, and by closely tying their performance to the prioritized countermeasures, the team has since improved uptake of both IPTp 1 and IPTp 3 or more from baseline median of 45% to uptakes greater than 90%.

Improving Malaria Case Management through Accuracy and Completeness of Data

Facilities in three high malaria burden counties (Siaya, Busia and Kakamega) formed Work Improvement Teams (WITs) in October 2015 to improve malaria case management data quality and reporting. They reviewed their malaria source documents in comparison with the reported DHIS data and identified gaps. The WITs developed a number of changes to test, which included: data quality audits, data validation, continuing medical education (CME), and on-the-job training on proper documentation. Through these efforts, within 5 months, 50% of their reported data in DHIS was accurate. By May 2017, 95% of facilities in the three counties had complete and accurate malaria data in DHIS.

Improving screening and management of malaria in pregnancy during first Antenatal Clinic Visit at Rongo Sub-County Hospital, Migori, Kenya

Rongo Sub-County Hospital formed a work improvement team (WIT) in November 2016 to improve malaria case management. They reviewed their malaria data to look for gaps for the first time and quickly saw that pregnant women were not routinely getting screened for malaria at their first antenatal care (ANC) visit which was compounded by poor documentation for those who were screened. The WIT developed a number of changes to test, which included: on the job training of staff on malaria in pregnancy, development and use of a malaria in pregnancy cascade tool, redesigning patient flow, client health talks on effects of malaria in pregnancy and importance of screening, and case management. Through these efforts, within 6 weeks, 100% of their first ANC visits had been screened for malaria. The team has been able to maintain this performance to date.

Improving Quantification of Parasitaemia on Confirmed Malaria Blood Smears at Matungu Sub County in Kakamega County

The USAID Applying Science to Strengthen and Improve Systems project (ASSIST) has been supporting quality improvement (QI) with a focus on improving malaria case management in Kakamega County since June 2014. In February 2016, Matungu Sub County Hospital (MSCH) formed a work improvement team with the goal of improving malaria testing of suspected malaria cases through quality improvement. Rapid improvement was achieved with this initial work that they began looking for new areas to work on. In August 2016, laboratory personnel were trained in expert microscopic examination of blood slides for malaria parasites. MSCH laboratory team was required to report blood slides of confirmed cases in terms of the number of parasites observed. Two months passed by without the team having begun quantifying malaria parasites on confirmed blood smears. The coach working with the ASSIST’s Project Officer picked this as an improvement theme, and at the end of September 2016 conducted process mapping for malaria testing, and root cause analysis for failure to quantify parasitaemia. Countermeasures were identified and small tests of change initiated in October 2016 to help the team improve. In the preceding four months, quantification of malaria parasites on blood smears confirmed to have malaria increased tremendously from zero to greater than 90%, and the team has since sustained this performance.

Improving Documentation of Malaria Suspects at Shiamakhubu Health Centre Outpatient Department in Kakamega County

During a clinical encounter of a suspected malaria patient in Kenya, it takes the triad of the clinician serving the patient, the morbidity tally sheet, and outpatient register to correctly capture the patient as a malaria suspect. Complete and accurate documentation of suspected malaria enables clinicians and malaria programs to determine testing rates, workload and thus planning and resource allocation. In cases where documentation is incomplete and inaccurate, malaria tests done and documented in the laboratory can be used to identify untallied malaria cases in the outpatient department. Shiamakhubu health centre is one the 12 centres of excellence in Kakamega County. In a bid to ensure that they account for all malaria suspects, they resolved to use their quality improvement team to address this area. Working with a baseline report in April 2016, the team developed countermeasures for the root causes of the problem. Implementation of this work began in May 2016 and through team work, 100% complete and accurate data was reported in August and through October 2016 until there was stock out of tally sheets and health care providers went on strike in November and December 2016.