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December 2001

Community Health Project Launched in the West Bank and Gaza

by Lani Marquez

It was a challenge getting there, but worth the effort for URC International Division Director Tisna Veldhuyzen van Zanten and Technical Advisor Ellen Coates to travel to Jerusalem to participate in the strategic planning and formal launching of the Improved Village and Community Health Services (IVCHS) Project.

URC is one of six implementing partners on the project, which is managed by PricewaterhouseCoopers and funded by the U.S. Agency for International Development. The three-year project will increase the accessibility, quality, and sustainability of health services to improve the health of Palestinian families living in the West Bank and Gaza.

During the week of October 22, implementing partner home office representatives and field staff from Gaza, Jerusalem, and the West Bank were able to meet together for the first time. As a result of long days of hard work, team spirit, and shared commitment to the IVCHS goal of improving the health of Palestinian families, the team succeeded in developing solid drafts of the project strategic plan and first annual work plan, which they presented during very positive meetings with USAID/Tel Aviv and the Minister of Health of the Palestinian Authority.

Those meetings were capped off with a ceremony at the Gaza-Israel border during which the U.S. Consular General, the USAID/Tel Aviv Mission Director, the Minister of International Cooperation of the Palestinian Authority, and the Minister of Health of the Palestinian Authority signed a Memorandum of Understanding formalizing cooperation on and commitment to the IVCHS Project.

Some of the challenges facing the Palestinian public health system are infectious diseases in young children; poor quality of care for newborns; micronutrient deficiencies in pregnant women, infants, and children; inadequate reproductive and maternal health care; lack of adolescent health services; and the very high incidence of accidents and injuries among children and adults. The IVCHS Project brings new approaches for dealing with these problems by integrating quality assurance, performance improvement, and behavior change communication in new ways to improve the delivery of maternal and child health and nutrition services.

The project will establish a new client-centered model of integrated service delivery, starting with one cluster of facilities in Gaza and one in the West Bank. Each cluster will include one referral hospital, the primary health centers located around it, non-governmental organizations (NGOs) in the area, and families and communities served by the hospital and primary health centers. Through a series of interventions, the project will not only address constraints to quality service delivery but also foster a culture of quality among clinicians, managers, educators, and other personnel involved in health services delivery. The project strives for active participation of communities in the definition and delivery of care. Eventually this model will be replicated throughout a network of approximately 20 hospitals designated by the Ministry of Health to receive equipment and technical support through the IVCHS Project.

An important aspect of the project's design is the commitment to working with health facilities, NGOs, private providers including midwives, communities, families, and individuals. A major focus will be to improve the quality of care and patient communication skills of facility and community-based health workers through updated clinical protocols, training, and facilitative supervision, and to strengthen the referral process between primary health care centers and local hospitals.

Accident and injury prevention is another priority. Accidents and injuries are a major cause of disability and death among children and adults in the West Bank and Gaza. The project will work with schools to promote safety awareness, conduct national campaigns to reduce and manage accidents and injuries, and engage the private sector to implement key safety measures, such as improved safety labels and safety caps on hazardous materials.

"URC's contribution to the project will be to apply our experience in quality design, team-based quality improvement, and quality monitoring to create a client-centered primary health care model that actively involves communities in the design and ongoing management of services," explained Veldhuyzen van Zanten, URC's corporate monitor for this project. The URC-led quality assurance and applied research, monitoring, and evaluation teams will work closely with the project's performance improvement and behavior change communications teams, as well as other experts on the IVCHS staff to integrate existing tools and develop new ones.

In addition to Veldhuyzen van Zanten and Coates, who will serve as URC's team leader, URC's IVCHS team includes a Maternal and Child Health Advisor/Medical Coordinator for Gaza, Dr. Yehia Abed, and two quality assurance experts and two public health research experts from the West Bank and Gaza. In addition, Dr. Abed will serve as Deputy Chief of Party for the project, coordinating all IVCHS activities implemented in Gaza. Each member of the field staff has extensive academic training and years of experience with health services delivery, research, and teaching, and most have worked for the Ministry of Health and/or Al-Quds University School of Public Health. Dr. Abed was formerly the Dean of the Gaza branch of the Al-Quds University School of Public Health prior to joining URC.

"It's really a privilege to work with this group of people," said Coates. "Their commitment to serving their fellow Palestinians and improving the health of Palestinian families, despite the personal risks they face in their day-to-day work, is enormous and inspiring."

"Meeting the Chief of Party and our Palestinian colleagues working on the project has been very rewarding and has stimulated us to bring forth the best that URC has to offer in order to help realize their vision to improve the health and well being of the Palestinian people," said Veldhuyzen van Zanten.

For more information on URC's work in the West Bank and Gaza, contact Ellen Coates, MPH, at ecoates@urc-chs.com.

Learning from Mutual Health Organizations in West Africa

In West Africa, Mutual Health Organizations (MHOs) are community and employment-based groups that finance health services for their members through pooled contributions and risk sharing. Interest in MHOs as an innovative approach to expand access to health care among disadvantaged rural populations and informal sectors in Africa has grown in recent years, as has the number of MHOs in countries like Senegal, Benin, Mali, Nigeria, and Ghana.

Photo courtesy of the PHRplus Project. PHRplus training tools will help improve the quality of care offered through MHO networks in West Africa

The U.S. Agency for International Development is supporting efforts to improve the effectiveness and sustainability of MHOs in West Africa through the Partnerships for Health Reformplus Project (PHRplus). URC, a partner on the PHRplus Project team led by prime contractor Abt Associates, Inc., is contributing to the development of tools to help MHO managers, government policymakers, and service providers improve the quality of health services and user satisfaction in MHOs and thus, their long-term sustainability.

Poor quality care in health facilities that provide services to MHOs is a key factor constraining the expansion of the mutual health movement. Lack of drugs, long waiting times, discourteous staff attitudes towards patients, and shortage of skilled providers are common problems that drive patients toward traditional healers or private health facilities, where fees are often much higher. Since MHOs work with both private and public providers, they can play an important role in intervening with the providers and facilities from whom they buy services to improve quality of care. Yet, many MHOs are relatively new and have limited expertise in negotiating with providers on quality issues and monitoring their actual performance.
URC staff Caroline Quijada, Associate Technical Officer, and Ed Kelley, Technical Officer, are leading a new PHRplus activity to develop training materials for MHO managers to teach basic quality assurance concepts and techniques. The manuals will also explain practical methods and tools for assessing, improving, and monitoring the quality of health services.

To guide the development of the training manuals, Quijada visited Ghana in November to train local health consultants to interview Mutual Health Organization managers and healthcare providers about their current practices. "There is anecdotal information that quality of care in MHOs is better than that provided by the Ministry of Health," explains Quijada. "We want to prove that this is so." The study will also look at the experience of Senegal, where MHOs are more advanced in their development, and Tanzania, to identify best practices of the more successful MHOs.

"The long-term goal is to develop tools that will help MHO managers contract with providers to ensure that they provide quality services to the mutual organization's members. We want to tell managers, 'These are provisions you can incorporate in your agreements with providers to make them accountable for quality of care.' Currently, few MHOs have contracts or formal agreements with providers, so there is no accountability," said Quijada. The manuals, which are expected to be completed early in 2002, will be produced in both French and English.

For more information on URC's work to improve the quality of services and sustainability of Mutual Health Organizations, contact Caroline Quijada, MHS, at caroline_quijada@abtassoc.com or Edward Kelley, Ph.D., at ed_kelley@abtassoc.com.

Teachers From Mexico Visit The Center For Human Services Under New Exchange Program

Mexican teachers Marisol Martinez and Sandra Zaragoza visited the Center for Human Services (CHS) in New Jersey this past summer to share their experiences, talk about their curricula, and learn new techniques from their counterparts in the United States. The teachers were among the first to visit under the new Program for Mexican Communities Abroad—Mexico Teacher Exchange Program between the Mexican State Department and CHS.

Mexican teacher, Sandra Zaragoza addresses the CHS audience

Established under the auspices of the Bi-national Education Program (PROBEM), the groundwork for the new Teacher Exchange Program was finalized this past summer between the Mexican State Department, represented by its Philadelphia Deputy Consul, Mr. Jacob Prado, and CHS. PROBEM provides for Mexican primary and secondary level teachers, mainly from regions of high emigration, to visit, for a period of four to six weeks, U.S. schools that serve large numbers of students from their region. In exchange, teachers from the U.S. visit the communities from which their students originate.

The High School Equivalency and Migratory Agricultural Workers and Seasonal Farmworkers with Disabilities Service Projects implemented by the Center for Human Services (CHS), the non-profit affiliate of URC, aims to provide job readiness, counseling, life skills, health education, high school equivalency, and post-secondary instruction to migrant farm workers and their families in New Jersey and Pennsylvania.

The program has already begun to highlight the benefits of cultural exchange, according to CHS New Jersey Project Director Louis Marino. Mr. Prado addressed CHS students during their visit to the Philadelphia Consulate and has visited CHS in New Jersey several times. In addition, Mr. Marino notes, Mr. Prado and CHS are enthusiastically planning local sporting meets and training courses for CHS teachers in New Jersey

The visit by the Mexican teachers has resulted in an awareness of the differences in teaching and learning styles between the cultures. Both teachers expressed their appreciation for the hospitality shown them during their stay and their affection for CHS students and staff. Ms. Zaragoza noted the warm welcome she received from CHS staff and students, saying she felt like she was "among family." Ms. Martinez observed differences in teaching and learning styles between the two countries, noting how much CHS students participate in their classes. In Mexico, she said, students learn in a more teacher-directed classroom environment.

Marisol Martinez receiving a certificate of achievement from CHS New Jersey Project Director, Louis Marino

CHS is also benefiting from a program established between The Mexican State Department and the Department of Public Education, through the National Commission of Free Text Books, which provides text book donations to U.S. schools and public libraries that provide services to groups of Mexican origin. The Mexican Consulate in Philadelphia has arranged for a shipment of Mexican books to be donated to CHS in New Jersey.

For more information on CHS programs benefiting Spanish-speaking immigrant populations, contact New Jersey Program Director Louis Marino at LouisMarino97@cs.com or Project Director Grogan Ullah at gullah@urc-chs.com.

November 2001

Contract Awards

by Lani Marquez

In September, URC was awarded a $1.9 million contract for the Underage Drinking Prevention Public Education Campaign. The purpose of the contract is to support the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention (SAMHSA/CSAP) in the development of the alcohol use component of the Centers for Disease Control and Prevention's (CDC) National Youth Media Campaign to Change Children's Health Behaviors. With URC's help, SAMHSA/CSAP will work in collaboration with CDC to design, implement, and evaluate an information and education campaign at the local level to reach and influence attitudes of youth, ages 9 through 13, about alcohol use. URC's Ruth Marshall will serve as Project Director. The contract period is for one year, with two option years to follow.

In October, the Center for Human Services (CHS) was awarded a Bilingual Education: Training for All Teachers grant from the U.S. Department of Education Office of Bilingual Education and Minority Languages. The purpose of the grant is two-fold: (1) to assist the Education Department of Western Maryland College (WMC) to increase its capacity to train school personnel who work with limited English proficiency students, and (2) to assist local school districts in Maryland and southeastern Pennsylvania to improve their ability to provide high quality educational services to limited English proficiency students. In collaboration with WMC, CHS will provide various professional development opportunities to public school teachers and administrators, including workshops, graduate courses in bilingual education, and an intensive summer training institute. The grant award amount is $155,512 per year for five years. The grant will be managed by Grogan Ullah in our Gettysburg, Pennsylvania office.
(Posted November 14, 2001.)

Job Aids Symposium Introduces Powerful Ways to Improve Health Worker Performance

by Cynthia Young

URC's Quality Assurance (QA) Project and the Child Survival Collaborations and Resources (CORE) Group hosted a Job Aids Symposium at the International Trade Center in Washington, DC, on May 24, 2001. The event, which was attended by over 70 participants, introduced the growing use of job aids as a promising way to improve health care provider performance in developing countries.

Bart Burkhalter, Associate QA Project Director, Operations Research; James Heiby, Medical Officer, USAID; and Tony Moore, President, Moore Performance Improvement, Inc.

The day-long event, with morning keynote presentations and afternoon break-out sessions, shared success stories, views, and evidence about the state-of-the-art in job aids and identified future developments that could make job aids more useful for child survival and international health programs. Participants also examined actual job aids that had been developed and tested in the field in a Job Aids Display area.

"We are trying to get out of old habits and look at new ways to improve performance," said Edward Kelley, PhD, Senior QA Advisor on the Quality Assurance Project, who introduced the morning session.

The traditional way of improving health worker performance in developing nations is through training. Growing evidence suggests, however, that these resource-intensive interventions may not always be sufficient and that well-developed job aids can be a powerful way of improving performance.

"Job aids are one of the fundamental strategies for improving health care performance," said James R. Heiby, MD, MPH, Medical Officer in the U.S. Agency for International Development Global Bureau's Office of Health and Nutrition and QA Project Manager. "Yet, for them to work, the use of job aids needs to be actively supported by the health system," he noted. "Sometimes, managers assume that simply distributing the job aids is all that is needed. Job aids are not something a manager just pulls off a shelf and expects a health care worker to use. Health workers need the active support of management to use job aids appropriately."

The display tables featured a wide array of job aids

Job aids also need to be created with care, he added. "Everyone understands that you need a high level of technical expertise to produce a good job aid. Yet what is not widely appreciated is that you also need expertise in the state-of-the-art in developing job aids. Both are necessary. The need for well-developed job aids is growing," Heiby concluded, "and this is just the beginning."

Tony Moore, President of Moore Performance Improvement, Inc., who has developed job aids for NASA, the U.S. Coast Guard, Southwestern Bell, and Johnson & Johnson, explained how job aids can be used across industries with dramatic, measurable results. Moore presented examples of incredible gains in productivity and quality, sometimes as high as 300 percent, with the use of job aids. While he advocates the use of data to monitor performance, detailed analyses in such cases only confirm the obvious. "You get such incredible changes in critical job measurements after using job aids that there is no need to do statistical analysis," Moore said. "It hits you right between the eyes."

"A job aid is used on the job while performing the task," he noted. "It tells you when to and when not to take action, and tells how to do it. Job aids are like having a coach who won't ... humiliate you, a gentle guide."
Yet, he added, there are some caveats. First, job aids are designed to address one cause of poor performance: information and use of information gaps. They cannot solve environmental or motivational problems. "Psycho-social barriers also are a big issue for doctors and nurses," Moore added. "They don't like sitting in front of patients and following a job aid. They feel it destroys their credibility."

However, this is a mistaken perception on the part of many health care workers, he noted. While conducting research in Zambia, Moore came upon a surprising attitude among patients. He asked patients, "How much would it bother you if your doctor followed a manual?" The patients replied that, in fact, they would prefer it. They had faith in the manual, they said.

Leading practitioners in the field also shared their successes at the symposium. Paula Tavrow, PhD, QA Project Deputy Director of Operations Research, spoke about the successful use of job aids to improve malaria treatment in Kenya and malaria diagnosis in Malawi. In Kenya, the QA Project developed job aids for shopkeepers that explained new malaria guidelines to them in Kiswahili. These job aids were then distributed by wholesale vendors. Outlets receiving the job aids were significantly more likely to provide correct anti-malarial treatment and information to mystery shoppers. In Malawi, improvements made to the instructional inserts accompanying rapid malaria diagnostic kits led to dramatically better use of the kits.

Federico R. Leon, PhD, of the Population Council, discussed his work to improve family planning counseling in Peru. He helped create job aids to assist health care providers to provide the most effective family planning counseling. They created method cards for counselors and method pamphlets for clients to take home. "The job aids help counselors to better administer the information exchanged with clients and represent a bridge, rather than an obstacle, in the relationship with them," he said.

Linda Bruce, Senior Program Officer in the Program for Appropriate Technology in Health (PATH), discussed the role of using a Clean Delivery Kit, a pre-packaged kit of essential hygiene and cord-cutting supplies and pictorial instructions, in the delivery of a baby. She also discussed the Vaccine Vial Monitor, which contains heat and time-sensitive labels on vaccine bottles that change color when the vaccine can no longer be used.

This vaccine vial monitor is accompanied by a simple companion job aid that describes the action needed based on the color of the label.
Afternoon break-out sessions addressed job aids for non-literate populations, job aids to improve clinical services, scaling up job aids efforts, and electronic job aids. At the end of the day, Moore led a short, roll-up-your-sleeves course on how to develop job aids, covering topics from content and type size to layout.

The symposium proceedings will be available from the QA Project in December 2001 and posted at http://www.qaproject.org/What'sNew.htm.
(Posted November 14, 2001.)

October 2001

CHS Inaugurates Bridgeton Center

by Michael Gebremedhin

It is not much to look at from the outside.

In fact, it is almost hidden from view behind the Post Office of this rural New Jersey town. There are no fancy flags or flashy awnings. Without the simple signboard, the Migratory Agricultural Workers and Seasonal Farmworkers with Disabilities Service Project could easily pass for an extension of the Post Office or yet another nondescript Bridgeton, New Jersey building.

But to people like Rocio García, this unassuming structure and the project it houses has become more than just "a place." Today, it has become a symbol of hope, self-improvement, and a better life.

"This is the first program I heard about that helps migrant workers," Rocio explains. She is a mother of three and a graduate of the project. Rocio initially dropped out of the course, but was pressured by her family to finish her studies. Having graduated from the program in 2000 with her General Education Development (GED) certificate, she now counsels the center’s clients about their long-term goals.

"Three of our graduates are teachers at the center," explains Louis Marino, the project director. "An additional two students are expected to become teachers soon." The school began as a small activity in the basement of the Bridgeton Library basement before moving to its current location on 100 North Pearl Street. The program consists of two education grants funded by the U.S. Department of Education. Approximately $180,000 is allocated to the disabled farmworker program and another $40,000 for the GED program.

The project, implemented by the Center for Human Services (CHS), the non-profit affiliate of URC, aims to provide job readiness, counseling, life skills, health education, high school equivalency, and post-secondary instruction to migrant farm workers and their families in several states including Delaware, New Jersey, and Pennsylvania.

The greater Bridgeton community echoed their appreciation of the project’s contribution when they gathered to inaugurate the new center on the evening of April 10, 2001. Leading the guests of honor was the Mayor of the Town of Bridgeton, the Honorable Michael Pirolli. Mayor Pirolli commended the efforts of the center and encouraged migrant workers to embrace the educational opportunity offered by the project. Also present were the Bridgeton Chief of Police, representatives of the Bridgeton business community, and the Honorary Mexican Consul of Philadelphia.

URC/CHS President Charles Pecarro presided over an official ribbon-cutting ceremony and congratulated the staff and students for the hard work that had gone into the center. "The Bridgeton Center for Human Services demonstrates that education is the key to the success and well-being of everyone who embraces it," said Pecarro. "CHS is proud of its commitment to migrant educational programs in New Jersey, Pennsylvania, and Delaware over the past twenty years."

Students entertained the crowd with traditional Mexican dances, theatrical interpretations, poetry readings, and enthusiastic singing.

As student Francisco Rey sees it, "the challenge now is to spread the word about the possibilities that the center can offer the people of our community."

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URC Appoints New Director for Program Development

by Lani Marquez

Dr. Neeraj Kak has been appointed to the position of Director for Program Development for URC/CHS, effective July 1. Prior to this appointment, he served as a Senior Advisor for the USAID-funded Quality Assurance (QA) Project, leading QA program development efforts in Jamaica, South Africa, and Asia.

"I am confident that Neeraj brings the collaborative style and management skills needed to lead our program development efforts," remarked URC President Charles C. Pecarro in announcing the appointment. "Neeraj knows URC/CHS well. His extensive experience in both health and non-health program development areas will be a great asset."

Neeraj began work with URC in 1986 as a Resident Advisor on the USAID-funded Asia Family Planning Operations Research Project and was based in Jakarta, Indonesia until 1991. During his tenure in Indonesia for URC, he also provided technical support to the National Family Planning Coordinating Board and the Ministry of Health in improving access to quality reproductive health services under the USAID/Indonesia-funded Private Sector Family Planning Project.

Before returning to URC in February 2000, Neeraj was a Senior Associate at The Futures Group, where he participated in the development of new program areas, such as HIV/AIDS, tuberculosis advocacy, coastal resource management, and public-private partnerships in health and environmental management. These activities gave him broad exposure to non-U.S. government funding agencies, such as the United Kingdom’s Department for International Development (DFID), the European Commission, the Asian Development Bank, and the United Nations Development Programme (UNDP).

"One of my goals as Director for Program Development," says Neeraj, "is to use synergies from our Domestic and International Divisions to expand our work in such areas as infectious diseases, patient safety, public-private partnerships in health and environmental issues, NGO strengthening, as well as to reach out to a new client-base within and outside United States."

Neeraj brings a wealth of technical expertise and education to lead URC’s business development efforts. He received his Ph.D. from the State University of New York, served as a post-doctoral fellow at the Johns Hopkins University School of Public Health, and holds a post-graduate diploma in business management. He has worked extensively on the design and evaluation of primary care and hospital-based services, and has provided technical consulting services to a wide array of clients, including ministries of health, private provider networks, and non-governmental organizations. An area of particular professional interest is applying management and research tools to strengthen program effectiveness and efficiency and to monitor performance.

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SAMHSA/CSAP Launches Bilingual Public Education Campaign

by Margaret Weiss Behrns

The population growth of Hispanics in the U.S. has finally hit the media full-force, as have various statistics on the young age and consumer potential of this group. Two sets of information about the growth of the Hispanic population are of particular interest to health professionals. One is the sheer number of Hispanic girls: today there are more than 6 million Hispanic girls under the age of 18. The other is the significant self-esteem and mental health problems these girls face, as recently documented by National Alliance for Hispanic Health (formerly COSSMHO) and the American Association of University Women.

In addition to dealing with peer pressure, developing their identity, making decisions, and forming goals, Hispanic girls are finding out what it means to be bicultural, learning how to negotiate value systems often at odds with one another, and fighting stereotypes and discrimination. Some of them are handling acculturation issues, immigration issues, and the tension that can develop in immigrant families when children learn English more rapidly than the parents and find themselves in more responsible roles than they may be ready for.

But that is not all they are doing. A significant number of Hispanic girls are using marijuana, cocaine, alcohol, and tobacco, and rank higher in rates of teen pregnancy, school dropout, depression, and suicide. To confront this growing problem, the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention (SAMHSA/CSAP) has just launched an ambitious new bilingual education campaign.

¡Soy Unica! ¡Soy Latina! is designed to help Hispanic girls ages 9-14 build and enhance their own self-esteem and mental health. The campaign’s print materials and Web information target issues of belonging, adaptation, and identity, and provide critical assertiveness, communication, acceptance, and decision-making tools. According to CSAP Director Dr. Ruth Sanchez-Way, "The campaign taps into the pride that already exists in the Hispanic community as a protective factor to prevent substance abuse."

The campaign’s bilingual Website (http://www.soyunica.gov) features a flash movie and eight main areas of interest:

The site also provides background information on the development of the campaign, and resources for Hispanic girls and their families.

Seven educational materials, such as posters, activity books, and a brochure, were developed to address the campaign goals, as well as other promotional materials such as bookmarks, stickers, and lanyards. The activity books, posters, and bookmarks are designed for specific age groups within the target population: one set is for girls 9-11 and the other for girls 12-14. Another activity book and the brochure are directed at mothers and caregivers. These innovative products, developed by URC staff on the National Clearinghouse for Alcohol and Drug Information (NCADI) Project, may be downloaded free of charge from the NCADI website (http://www.health.org).

For more information about this campaign, please contact Margaret Weiss Behrns, Multicultural Outreach Manager for the National Clearinghouse for Alcohol and Drug Information, at mbehrns@health.org.

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Improving Health Care in Russia: QA Project Demonstration Models Help Reduce Maternal and Newborn Mortality

by Cynthia Young

Until recently, the leading cause of maternal mortality in the Tver region in Russia was pregnancy-induced hypertension. In the same region, respiratory distress syndrome was the single largest cause of early newborn deaths. Now, due to a unique partnership between the Russian Federation and the United States to improve health care in Russia, these causes are not number one any more.

Working together with the Russian Federation’s Ministry of Health and local health departments, the USAID-funded Quality Assurance (QA) Project and the Agency for Health Research and Quality (AHRQ) joined efforts to improve the quality of health care in the areas of primary care and maternal and child health last year. This cooperation took place as part of the U.S.-Russia Health Committee, established under the US-Russia Joint Commission on Economic and Technological Cooperation.

Quality assurance experts Dr. M. Rashad Massoud, QA Project Associate Director for Europe, Asia, and the Near East, and Dr. Anna Korotkova, Chief of the Methodological Center for Quality Management in the Russian Ministry of Health’s Central Public Health Research Institute, led the pilot program. Dr. Massoud and Ms. Hany Abdallah, MA, MHS, QA Project Quality Assurance Specialist, described the program’s accomplishments recently at a presentation to the Agency for Health Research and Quality in Rockville, MD.

Dr. Massoud explained that multidisciplinary teams, led by a steering committee of regional senior physicians and health leaders, addressed significant local health problems in the region of Tver Oblast. (An oblast is an administrative region). Local health leaders who were able to choose a specific health problem to address felt a strong sense of project ownership-–a crucial factor in the project’s success and subsequent expansion. "We felt if they worked together and tackled the issues that were important to them, they would be excited about the project and contribute to a higher effort later," Dr. Massoud said.

In Tver, the local team addressed two Maternal and Child Health actions: to lower maternal mortality due to pregnancy-induced hypertension (PIH) and to reduce newborn mortality due to respiratory distress syndrome (RDS). Mothers with PIH also tended to have a higher rate of newborns with RDS and infant mortality.

Pregnancy-induced hypertension was the leading cause of maternal mortality in Tver, the site of the three facilities that participated in the pilot project. Stressing evidence-based medicine as the basis of content knowledge on pregnancy-induced hypertension, the QA Project helped develop a new system of care for pregnant women. The results in the demonstration facilities included a dramatic drop in maternal mortality to no maternal deaths from PIH. Results included a 77 percent reduction in maternal hospitalization due to PIH, a 60 percent decrease in newborn complications, and an 87 percent reduction in the total cost of care for women with PIH.

At the same time, many newborns with RDS were dying even before they arrived at hospitals due to inadequate emergency care at home and during transportation. Maternity hospitals and emergency rooms also lacked adequate neonatal care. In Tver, RDS caused 66 percent of premature newborn deaths. The QA Project helped reverse this rate by redesigning the system of neonatal care at five facilities. A central referral unit, a neonatal intensive care center, was also set up at a children’s hospital in Tver City. A neonatal ambulance system was created to transport babies to the center, and training was conducted to resuscitate, stabilize, and transport infants to the central unit.

The results of this pilot project were extraordinary. The newborn survival rate after resuscitation soared to 93 percent, babies transported to the center with normal body temperature rose by 46 percent, and neonatal mortality was reduced by 63 percent. These neonatal care services are currently being expanded to all 47 hospitals in Tver Oblast.

A before-and-after study, done at two of the project hospitals using all PIH patients six months before and after the intervention, showed a substantial decrease in the cost of maternal care as a result of the new guidelines, said Ms. Abdallah. "Overall, there was an 87 percent savings in the average total cost of care," she said. "This was driven by a reduction in the number of hospitalizations, reduced lengths of stay, and a decrease in drug costs and average cost of care per patient." It illustrated that improved quality can be accomplished at reduced costs.

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