Performance and Quality Improvement in Ethiopia

Where has OPQ been used?

  • Health centers

Key lesson:

  • Training, joint supportive supervision, self-assessment, and action planning improve quality of care

In Ethiopia, performance and quality improvement is a strategic objective of the five-year Community Prevention of Maternal-to-Child Transmission (CPMTCT) partnership between IntraHealth and USAID, which provides support for 519 health centers in Addis Ababa, Amhara, Oromiya, Southern Nations/Nationalities and People, and Tigray regions.


pmtct training EthiopiaTraining is one intervention in IntraHealth’s quality and performance improvement efforts. The organization developed new tools to aid monitoring of the quality of its trainings, which are offered to health workers at every level of the Ethiopian health system, from federal to woreda. IntraHealth has assisted the Ethiopian Federal Ministry of Health (FMOH) in the preparation of national quality improvement guides, and, in accordance with government recommendations, has provided performance and quality improvement training to supported health center staff.

In addition to this training, health centers also benefit from quality improvement tools. To assist Primary Health Care Units (PHCUs) in building their capacity in performance and quality improvement, the project developed a guide for monthly meetings. This guide provides a process and tools for PHCUs to review their performance, identify gaps and solutions, and set targets and plan activities for the coming month. Use of the guide’s improvement process was associated with increased service uptake in general and reduced loss-to-follow-up (LTFU) of HIV-positive pregnant women and HIV-exposed infants in particular. In Tigray, for example, when high levels of LTFU were recorded in Year I, the project surmised that patients might be receiving antiretroviral drugs (ARV) at non-CPMTCT facilities. In response, wall charts were implemented in order to track these patients at the various locations where they might be seeking care. Post-implementation, LTFU rates were dramatically reduced. Finally, as part of IntraHealth’s commitment to gender mainstreaming, U.S.- and field-based teams have collaborated on the creation of new woman-friendly maternity care training manuals, which have since been integrated into all project-supported trainings.

Supportive SupervisionEthiopia_PQI_pkg

Supportive supervision is another key focus of IntraHealth’s quality improvement efforts. As of 2012, a revised performance/quality improvement and supportive supervision training package, including a trainer’s guide, participant’s handbook, and reference manual has aligned these tools with those used in other IntraHealth country programs. One hundred seventy regional, zonal, and woreda health workers in all five project regions were trained using this revised package. Following the training, health centers received regular joint supportive supervision (JSS) visits from different levels of health mangers using a standard supportive supervision checklist. These JSS visits focused on antenatal care (ANC), delivery, family planning, and under-five services, as well as laboratory and pharmacy services. Additionally, health centers received follow-up visits and mentoring on self-assessment.

In response to the Year IV quality of care assessment, 94% of facilities reported that the JSS checklist was helpful to them. As one respondent said, “I have found the JSS very effective in providing solutions and extending the health service coverage to the maximum.” Particularly valuable elements of the JSS process included early identification of service delivery gaps, development of action plans, clarification of staff expectations, and self-assessments, which respondents said had increased staff motivation. The CPMTCT Project efforts in building the capacity for performance and quality improvement and supportive supervision, along with community mobilization interventions, have paid off.

CPMTCT Project Results

The Year IV quality of care assessment found that 80% of those facilities that received CPMTCT project support for the full four-year period had met quality standards. For example, health center tracking charts and mother support group reports during the last two years of project support were reviewed in three health centers supported by the project. According to these records, 88 HIV-positive pregnant women were identified during their first ANC visits. Among HIV-positive mothers, 90% (N=79) received ARV, either prophylaxis (N=38) or treatment/HAART (N=41), to prevent mother-to-child transmission. 68% (N=60) mothers delivered (1 still birth) and 20% (N=18) mothers were not yet delivered. Nine mothers 10% (N=9) were lost to follow-up. A total of 68% (N=60) HIV-exposed infants received ARV prophylaxis and had dried blood spot testing. These percentages far exceed the national averages reported in 2012, in which only 40% of HIV-positive pregnant women and 24% of HIV-exposed infants received ARV prophylaxis, respectively.

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