Evaluating quality improvement processes and strategies across 3 African countries
Background: Prevention of mother-to-child HIV transmission (pMTCT) is complex, requiring that sequential, linked systems work well independently and together, and engage patients throughout the pMTCT cascade. A systems view can highlight inefficiencies at each step of the cascade, better explain how steps interrelate, and foster novel, iterative approaches to improve pMTCT and identify best practices for scale-up. Few rigorous evaluations have investigated the impact of systems analysis and improvement interventions in low-income countries.
Methods: A cluster randomized trial in 18 intervention and 18 control facilities split equally across three study countries with diverse histories, health systems, and HIV burden (Mozambique, Cote d’Ivoire, Kenya) is underway to assess the effectiveness of a five-step systems analysis and improvement intervention. The health facility-based intervention is a mentored process of 1. Cascade analysis with optimization functionality, 2. Process mapping, and 3-5. Continuous Quality Improvement (CQI) cycles of planning, implementing, analyzing, and re-iteration. Steps 1 and 2 are designed to identify and prioritize service areas for improvement (HIV testing, ART provision, postpartum care, PCR testing, pediatric cART initiation), and generate workflow modifications for testing. Steps 3-5 include the CQI cycle. The intervention, which targets nurses and nurse managers, will be evaluated over nine months, focusing on process measures that reflect improved pMTCT efficiency and quality.
Results: The five-step intervention was previously piloted over a 6-month period in Mozambique, and significantly adapted to meet the needs and competencies of district-level nursing managers. Pilot results highlighted the importance of leadership and staffing patterns in implementation success. The pragmatic intervention trial will be completed at the end of 2014, and main impact and process evaluation results will be presented.
Implications: This trial is a rigorous evaluation of a simple, iterative and contextually appropriate intervention to understand and improve pMTCT services. Results will provide evidence of its effectiveness, which may be applicable for testing in other similarly complex areas.