Topics

Community Health

Community Health System

As the complex needs of people facing the double burden of health issues and socio-economic difficulties are increasingly identified and addressed, the importance of community-level health and social services is magnified. Improvement methods can be applied at the community level to address the quality and coverage of health and social welfare services, strengthen linkages between the community and the health system, and enhance the capacity of existing groups and networks to affect health issues in their own communities. 

A particular area of focus for improvement in community health is to strengthen the effectiveness and sustainability of programs that rely on community health workers (CHWs). Due to large catchment areas and numbers of households they are expected to cover, CHWs are frequently inadequate to provide services to all households needing them.  Although CHWs are usually linked to facilities, facility health care teams often do not have the time or capacity to address the challenges facing CHWs. Leveraging existing networks and indigenous structures to work together to improve the health of community members can improve CHWs’ acceptance, morale, and performance.

Family Planning and Reproductive Health

Family planning allows women and couples to determine whether and when to have children. The ability to make these choices is fundamental to healthy families and communities worldwide. Improvement methods can help solve the many operational challenges to delivering family planning and reproductive health services in different settings, including integrating family planning with other health services, assuring the availability of a well-balanced mix of contraceptive methods, and increasing the effectiveness of family planning counseling to increase uptake of modern contraceptive methods at both the facility and community levels.

Gender

Women, men, boys, and girls should have equal opportunities to be healthy and to reach their full potential. Yet differing health-related needs and different social, economic, and cultural barriers to accessing care thwart the ability of certain groups to access and benefit from health care services. Gender is a social determinant of health across all countries and cultures. Gender gaps and issues affect access to, utilization of, and quality of care for women, men, boys, and girls. To truly improve the quality of all care for all, these gender gaps and issues must be explicitly recognized and addressed by providers, facilities, and health systems, and this is especially true in quality improvement activities. In this video, watch Dr. Taroub Harb Faramand of WI-HER, LLC explain how addressing gender considerations in improvement work leads to better outcomes.

Community Quality Improvement Team in Buikwe, Uganda

We take an improvement approach to integrate gender through the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project. By collecting and analyzing sex-disaggregated data and systematically identifying and analyzing gaps in outcomes among women, men, boys and girls, we evaluate what is causing poorer outcomes among one group, and design activities to respond to the needs of males or females to close the gap. We do this in improvement activities across health areas and beyond, including non-communicable diseases (NCDs) programming, HIV and ART services, OVC services, and more. We promote partner involvement in programs targeting either males or females, such as engaging male partners and fathers in ANC visits and PMTCT programs to improve outcomes for mothers and babies, and engaging female partners of males who undergo the VMMC procedure to improve follow-up and decrease adverse events. 

Our innovative and effective six-step approach to identify and close gender-related gaps improves health outcomes for all, and we utilize locally-owned, culturally-sensitive, and innovative models. We recognize that myriad factors at multiple levels of society affect gender norms that influence risk factors, access to care, utilization of care, and equality of treatment and we work to respond to these norms in concert to generate shifts in thinking and behavior. We address gender gaps and issues at the individual, household, and community levels, when necessary, though staff and community sensitization trainings, and we consider the varied contextual factors that drive outcomes for women, men, boys, and girls in the design, implementation, and evaluation of our programs.

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Health Workforce Development

Health Workforce training with model baby

Crucial for efforts to provide universal health coverage is the strengthening of the existing health workforce – maximizing the talents that are currently available and building mechanisms to ensure that productivity, performance, and engagement will continue to improve as these resources grow and evolve.  In order to obtain desired results, it is necessary to both explore and develop the evidence to enhance our understanding of the factors that influence health worker outputs and clinical outcomes.  This is accomplished through innovative research that is then used to develop practical tools and guidance that is applied to analyze and strengthen health workforce planning, management, and development.  Applying improvement approaches to engage health workers in providing quality care and to empower teams to deliver better services to more users is an integral part of systems strengthening. 

In many countries the performance of health workers is constrained by factors such as regular stock-out of medicines, shortage of supplies, high levels of staff turnover, unclear job expectations, and limited feedback and supervision. Growing evidence suggests that improving the productivity and engagement of health workers and addressing performance factors within the health workforce contribute to improved care outcomes.  Improvement methods can help to:

  • Clarify roles and expectations, assess work distribution and rationalize tasks among team members, and introduce measurement of performance
  • Develop and test incentives, rewards and consequences that reinforce strong performance and discourage poor performance, from verbal recognition to career path and bonus mechanisms
  • Strengthen performance feedback mechanisms among members of the care delivery team, supervisors, and community members
  • Enhance the work environment, including both the physical environment (including safety and the availability of supplies) and the non-physical environment (including management practices that build confidence and security, mechanisms for coordination and communication, and protection from violence or harassment), to enable health workers to perform at their best
  • Build the competencies needed to implement tasks and perform at expected levels

 

HIV and AIDS

HIV Peer Mentors in Morogoro

As coverage of HIV prevention, care and treatment services expands and programs mature, greater attention is being paid to strengthening the capacity of health systems to provide and sustain high quality HIV and AIDS services, including antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), HIV counseling and testing, integration of HIV services with other clinical services, home-based care and community support, injection safety, and medical waste management.

Improvement methods help HIV and AIDS programs to: 1) provide services for all who need them, 2) retain all those who access services in the continuum of care, and 3) achieve optimal health outcomes for all those who are retained in care.  Strategies to improve coverage of HIV-infected mothers by PMTCT services, especially in antenatal care and at delivery, and improve the follow-up of mother-baby pairs can maximize the uptake of PMTCT services and promote HIV-free survival by assuring that all eligible infants and mothers get needed PMTCT services.  Adult treatment, care, and support can be improved by applying a chronic care model to service delivery and strengthening linkages with community and home-based care.

Innovative Technologies

Innovative technologies like mobile devices, electronic medical records, and interventions based on human performance technology are increasingly being deployed to respond to health care delivery challenges in low-resource settings. To ensure that technologies achieve the greatest impact, they must be designed to respond to important system gaps and their introduction should be grounded in strategies that strengthen essential health system functions like health information systems, service delivery, and provider performance.

Improvement Framework for Leveraging mHealth and eHealth to Strengthen Systems

The USAID ASSIST Project is testing and evaluating how mHealth and eHealth can improve the efficiency and effectiveness of care and support processes, enhance the performance of human resources for health, and improve coordination and communication between health system levels and with clients.  The project’s Framework for Leveraging mHealth and eHealth to Strengthen Health Systems highlights critical system and quality gaps and describes how improvement science can enhance the development and testing of technologies to improve information systems and data, health workforce management, service delivery, and supply chain management

Maternal, Newborn, and Child Health

Mother with baby

In the last 20 years, great strides have been made in reducing child and maternal deaths.  However, child and maternal deaths still remain unacceptably high. In 2013, 6.3 million children died before their fifth birthday, and even now some 800 women and girls die each day in the process of giving life, largely from preventable causes. Strengthening essential system functions to reliably deliver high quality, life-saving interventions for leading causes of maternal, newborn, and child mortality is a major part of USAID’s Ending Preventable Child and Maternal Deaths (EPCMD) strategy. The USAID ASSIST Project supports the global EPCMD agenda by:

  • Testing and implementing innovative, cutting-edge quality improvement and service delivery approaches in maternal, newborn, and child health (MNCH), such as collaborative improvement, process redesign, and integrating routine and complications care across system levels
  • Developing, testing, and disseminating technical frameworks, approaches, and tools that can increase the efficiency, effectiveness, cost-effectiveness and sustainability of health system strengthening and quality improvement initiatives in support of the USAID EPCMD strategy, including strategies to integrate gender considerations in care delivery
  • Building government and implementing partner capacity to apply improvement methods across health system levels (community, clinic, hospital, district, regional, central) to improve, scale up, and sustain high-impact, low-cost, people-centered MNCH and family planning (FP) services for leading causes of maternal newborn and child morbidity and mortality in USAID priority countries
  • Strengthening frontline health worker and manager skills, motivation, and performance through integrated clinical and quality improvement (QI) capacity building and through engagement of health workers in making improvements in their local health care systems and processes
  • Supporting the development and testing of MNCH quality of care indicators, strengthening routine health information systems to enable regular tracking of quality measures at service delivery level, and promoting accountability at global, national, and sub-national levels

Drawing on extensive experience support the planning, implementation and evaluation of MNCH improvement programs in different countries and regions, USAID ASSIST also contributes to global learning about gaps in care processes and how to best support health system functions to deliver high-impact, cost-effective MNCH services to decrease preventable maternal and child deaths.

Nutrition

The nutrition assessment, counseling, and support (NACS) approach aims to improve the nutritional status of individuals and populations by integrating nutrition into policies, programs, and the health service delivery infrastructure.  Improvement methods can help to strengthen the linkage between communities and points of care for nutritional services to improve the coverage, compliance, referral, and follow-up of people of all ages with special nutritional needs, including pregnant and lactating women, young children, and persons living with HIV or tuberculosis.

Nutrition MUAC

Integrating nutrition support into existing health services can be challenging. Health care providers may lack the technical knowledge and skills to deliver the correct care; high staff turnover make one-off training in nutrition assessment and follow-up unsustainable; low staff numbers make it hard for clinics to handle the increased workload required to integrate a new service into their already busy clinics; and supply chain issues mean that supplies of specialized food products are not always available at clinics. These challenges can be addressed by improvement interventions to build technical skills, improve the efficiency and effectiveness of service delivery, and strengthen data systems at all levels.

Vulnerable Children & Families

School Children in Nigeria

Due to the long-term effects of HIV, AIDS and poverty, many countries are home to increasing numbers of vulnerable children requiring care and support beyond what can be provided by their families. Government, civil society, and the international donor community have attempted to fill those gaps in care and support through the provision of services to millions of at-risk children. Standardizing the delivery of child and family welfare services is a first step toward achieving a systemic and sustained response to the needs of vulnerable children and families. Improvement methods can help national coordinating bodies and implementing partners to develop and put in practice outcomes-oriented standards for vulnerable children and family services. Improvement methods can also test models to support and strengthen government capacity to protect most vulnerable children--those at risk of or living outside of family care.

Zika

Photo by Dr. Karen Orellana

The recent emergence and rapid spread of the Zika virus presents a grave, new challenge for health systems and practitioners across the Zika-affected regions, as they work to address the unique health needs and concerns of individuals and families affected by the epidemic.

Zika is spread primarily through the Aedes mosquito – the same species of mosquito that spreads dengue and chikungunya – but the virus can also be transmitted via sexual contact. Common symptoms of Zika for an otherwise healthy adult include mild fever, skin rash, conjunctivitis, muscle and joint pain, malaise or headache, lasting up to a week.

However, most concerning for health workers is that Zika is passed from a pregnant woman to her fetus during pregnancy. While the symptoms for an adult are mild, Zika infection during pregnancy can have grave consequences for the growing fetus. Zika infection during pregnancy has been linked to an increase in birth defects across the Zika-affected regions, particularly a serious birth defect called microcephaly, which results in unusually small heads and brain damage in newborns.

As part of the Zika virus epidemic emergency response, ASSIST is providing intensive assistance to the Ministry of Health in five countries – the Dominican Republic, El Salvador, Guatemala, Honduras, and Nicaragua. Activities supported include: conducting a baseline assessment of the quality of Zika-related care, revising Zika-related clinical guidelines, training health care providers on counseling skills, improving Zika-related clinical processes, conducting face-to-face and virtual courses on Zika-related health care, implementing a Zika quality improvement program, and cultivating a Zika community of practice to rapidly scale up learning across all affected countries.

In addition to the resources provided here, ASSIST maintains a website in Spanish with exclusively Zika-related content: www.maternoinfantil.org/zika.