1. 1 Challenges and successes in maintaining gains in quality of care and institutionalizing quality improvement in Niger Maina Boucar, MD, MPH USAID - Health Improvement Project University Research CO, Niger

2. USAID HEALTH CARE IMPROVEMENT PROJECT Presentation Outline What is institutionalization? Context and process in Niger: How well have we institutionalized gains in quality of care and QI? What have we learned and where do we go from here?

3. USAID HEALTH CARE IMPROVEMENT PROJECT Institutionalization “Establish and maintain QI [and improvement results and practices] as an integral, sustainable part of a health system or organization, woven into the fabric of daily activities and routine” Silimperi et al, 2002 How can we operationalize this definition and make progress towards it? How can the national health system (facilities, district, regions, central MOH) own this process?

4. USAID HEALTH CARE IMPROVEMENT PROJECT. GOAL: reduce maternal/ newborn mortality by strengthening local health systems to implement and scale up high-impact, evidence-based, maternal- newborn interventions SCALE: 52 health facilities (tertiary, district and peripheral maternities) COVERAGE: Monitoring 3,085 births per month (27% of all public facility births) INTERVENTION PERIOD: July 2006-December 2008 Niger EONC Collaborative: focus, scale, and coverage

5. USAID HEALTH CARE IMPROVEMENT PROJECT Sustaining gains for active management of the third stage of labor (AMTSL) in 20 sites in Niger

6. USAID HEALTH CARE IMPROVEMENT PROJECT Specific objectives for achieving institutionalization Site level: Ensure sustaining gains in quality of EON care and related QI activities Ensure availability of essential resources for quality health care Strengthen implementation of QI activities and application to new areas District and Regional level: Strengthen (technical and organizational) capacity of higher levels of the health system to provide adequate support to health facilities National Level: Create an enabling policy and strategic environment for implementation of QI at all levels of the health system

7. USAID HEALTH CARE IMPROVEMENT PROJECT Institutionalization of QI Implementation of QI at site level: –During collaborative: 88% of QI tasks implemented; 6 months after: 85%; 20 months after: 71% –12 of 20 sites applied QI to a new area on their own initiative after collaborative ended Institutionalization enhancing activities –Mean percentage of institutionalization-enhancing activities implemented at each level –Variation seen across sites, districts and regions SiteDistrictRegionCentral MOH 56%46%55%40%

8. USAID HEALTH CARE IMPROVEMENT PROJECT Lessons learned The process of institutionalization must be integrated into the initial implementation plan Build QI and institutionalization activities into existing structural and organizational opportunities (e.g., supervision, regular meetings, HIS) Make use of local clinical staff as trainers and coaches for QI, as they can best understand how to integrate this into daily work

9. USAID HEALTH CARE IMPROVEMENT PROJECT Lessons learned (continued) For institutionalization, it is important to not only focus on clinical activities, but also on managerial support and planning (needs a whole systems view) Institutionalization needs to be a focus at the policy level and be integrated into subsequent strategies and health development plans

10. USAID HEALTH CARE IMPROVEMENT PROJECT Message for others Leaving institutionalization “for later” will cost you more in the end Institutionalization is the responsibility of those inside the system As part of this work, we developed tools for measuring and frameworks for enhancing institutionalization – take them and improve on them!

11. 11 “Institutionalization is a journey, not an event” Thanks Full report can be accessed at www.hciproject.org http://www.hciproject.org/node/2126 www.hciproject.org http://www.hciproject.org/node/2126