USAID Health Care Improvement Project (HCI) | Global
Funded by: US Agency for International Development
Project Duration: 2007 to 2014
Countries: Global, Afghanistan, Zambia, Malawi, Nicaragua, Mali, Indonesia, Swaziland, Mozambique, Pakistan, Ukraine
EnCompass LLC; FHI 360; Health Research, Inc.; Initiatives Inc.;
Institute for Healthcare Improvement; and Johns Hopkins University Center for
Communication Programs (subcontractors)
The Health Care Improvement Project (HCI) is the global
mechanism of the US Agency for International Development (USAID) to provide
technical leadership and country assistance for the application of modern quality
improvement (QI) methods. HCI’s goal is to make measurable gains in the quality
of health care as well as improve health workforce management. URC supports
USAID-assisted countries to improve the quality and impact of health services
through the global Task Order 3 issued under the USAID Health Care Improvement
Indefinite Quantity Contract.
Through HCI, URC seeks to develop the capacity of host
country health systems to apply modern QI approaches to make essential services
better meet the needs of underserved populations; improve efficiency and reduce
the costs of poor quality; and improve health worker capacity, motivation, and
retention. The project builds on 20 years of URC experience and innovation to
adapt QI approaches that have been highly successful in industrial
countries—such as continuous quality improvement (CQI), quality management/
total quality management, improvement
aids, self-assessment, and performance-based incentives—to the
context of USAID-assisted countries.
Read more about HCI at the project's website.
- HIV/AIDS: HCI supports
assessments and system strengthening related to antiretroviral therapy (ART),
prevention of mother-to-child transmission of HIV (PMTCT), HIV counseling and
testing, integration of HIV services with other clinical services, and lab
services. The project is also supporting countries in assuring HIV-free
survival of children born to HIV-infected women and in providing nutritional
assessment, counseling, and support to HIV-positive patients.
- Maternal, newborn, and child health (MNCH): HCI is applying QI methods to strengthen the continuum of
integrated maternal, newborn, and child health services at community, primary,
and reference levels, with a focus on maternal and child health (MCH) priority
countries. In collaboration with the World Health Organization (WHO), HCI
contributed to a global effort to develop and test a Safe Childbirth Checklist to improve patient
safety and quality of delivery care for new mothers and their babies. HCI also
supported global and regional initiatives in newborn health, including Helping
Babies Breathe and Kangaroo Care, working in collaboration with other USAID
implementing agencies to harmonize tools and approaches for improving MNCH
- Orphans and vulnerable children (OVC): HCI supports the PEPFAR Care that Counts Initiative to
improve the quality of programs serving OVC. The initiative assists national
coordinating bodies and implementers to develop and implement outcome-based
standards for OVC services. HCI is also developing the capacity of regional
institutions in Africa to provide technical support for improvement of child
protection and other services for vulnerable children and families.
- TB: HCI is
strengthening TB case management and directly observed treatment (DOTS), the
management of multi-drug resistant TB, and the integration of TB and HIV care
in selected high-burden countries.
- Health workforce development: HCI is applying collaborative improvement and other QI
approaches to strengthen health worker engagement, productivity, retention, and
performance management. The project is collaborating with the Global Health
Workforce Alliance and other partners to develop strategies to improve the
effectiveness of community health workers (CHWs) and has developed a toolkit
to assess the functionality of CHW programs. HCI also developed a framework
for improving the quality of in-service training programs to ensure their
sustainability, effectiveness, and efficiency. The project has also conducted
research on the use of expert patients and other task-shifting interventions
and on strategies to improve the engagement and productivity of health workers.
- Knowledge management: HCI supports a global knowledge management system to gather and
share learning from QI teams and country experiences through the project's main
Improvement website and related sites aimed at regional audiences in
These sites offer extensive resources on QI methods and approaches for
improving health services delivery and seek to facilitate the sharing of
practical knowledge, best practices, tools, and implementation experiences to
support improvement activities in HIV/AIDS, MCH, TB, malaria, services for
vulnerable children affected by HIV/AIDS, and health workforce development.
- Research and evaluation: In addition to country technical assistance, HCI supports a
focused program of research and evaluation related to the spread
and institutionalization of best practices and improvement methods,
accelerating learning and results through collaborative improvement, improving
the efficiency of QI interventions, adapting QI methods to community-level
services, enhancing QI team performance, and documenting the cost-effectiveness
and cost implications of QI interventions.
- Technical leadership: HCI provides global technical leadership for USAID's
initiatives to improve health care by collaborating with other international agencies
and by disseminating QI results, tools, and methods to support the
strengthening of health systems in USAID-assisted countries.
- The project has developed a framework for improving the quality
of care for HIV and AIDS patients; it focuses on coverage of those eligible for
ART, retention of patients in care, and improving patients’ clinical outcomes.
The framework is being applied in Cote d’Ivoire, Tanzania, Uganda, Russia, and
- HCI has developed a Learning System for Improvement that
provides tools for QI teams and managers to strengthen documentation, analysis,
sharing, and synthesis processes within their improvement efforts.
- The HCI-developed CHW program assessment and improvement matrix
(CHW AIM) is
helping USAID implementing partners assess the functionality of 1) programs
that use CHWs to deliver maternal care and 2) managers to strengthen
documentation, analysis, sharing, and synthesis processes within their
- The project’s web-based knowledge management system, the Health Care Improvement Portal,
offers methods, approaches, and resources for improving health care and a unique
resource to allow QI implementers worldwide to share reports about their health
care QI experiences.
- The human resources improvement collaborative in Niger, conducted
in 2009–2012, increased the percentage of health workers with job descriptions
from 7.5% to 98%. During that period, contraceptive prevalence rose steadily from 9.6% to 36%;
postpartum hemorrhage declined from 2.0% to 0.06%; the case fatality rate for
children under five with severe malaria fell from 15% to 4%. The Niger Ministry
of Public Health adopted this approach to human resources improvement on a
national level and launched implementation in three additional regions with its
- In Uganda, 34 HCI-assisted facilities working on essential
newborn care (ENC) increased the provision of three priority ENC components and
early breast feeding from less than 3% to 88% in 16 months. Follow-up visits for
the newborn within seven days showed less improvement, increasing from 0% to
- In Tanzania, teams of providers made changes in counseling,
clinic organization, and documentation. They measured an increase in the
percentage of HIV-positive women attending antenatal care who were assessed for
ART from 44% to 89% in five months. In another set of facilities, changes in
human resources management (such as having detailed job descriptions and
assigned responsibility) combined with changes in the clinical information
system (added TB testing) increased TB screening for HIV patients from 35% to
99% over 17 months. Another set made different human resources changes
(organizing patient follow-up as a clinic function and shifting tasks for
defaulters to lay volunteers) and measured a drop in loss to follow-up from 7%
to 2% per month.
- In Bolivia, TB cure rates in the El Alto region rose from about
60% to 85% over the course of 12 months of improvement efforts. When the
interventions that had been successful in El Alto were shared with 39
improvement teams in Cochabamba, a similar increase was observed in about two
- In Kwale District, Kenya, teams used collaborative improvement
approaches to integrate antenatal and PMTCT services. Over a 17-month period,
completion of four ANC visits rose from 26% to 57%; the percentage of expected
deliveries in the facility rose from 23% to 51%; the percentage of pregnant
women receiving iron tablets rose from 23% to 98%; and the percentage of women
with hemoglobin measurements in their charts rose from 34% to 68%.
- In five hospitals in Kabul, improvement teams implemented
changes in family planning counseling that focused on cultural sensitivities.
Over nine months, the percentage of postpartum women leaving the hospital with
their preferred method rose from 12% to 86%.
- In Nicaragua, teams in four hospitals tested changes to reduce
the incidence of neonatal sepsis. With the participation of lab staff, they
introduced a standardized laboratory-screening bundle, including a standardized
statistical package for analysis and a core list of risk factors for neonatal
sepsis. Over 3.5 years, the incidence of neonatal sepsis dropped steadily, from
70.1 per 1000 births to 2.6..
- HCI contributed to the development of the new Safe Delivery
Checklist and its field testing by WHO, the Harvard Medical School, and the
World Alliance for Patient Safety.
- HCI’s work to adapt QI approaches normally applied to clinical
care settings and apply them to address social services for OVC (including
education, food and nutrition, shelter and care, legal protection, health care,
economic strengthening, and psychosocial support) provided mainly by volunteers
at the community level is helping to shift the focus of OVC programs from
inputs to outcomes that make a difference in these children’s lives. Evidence from
Ethiopia shows that this innovative application of QI—proven successful in
clinical health care—is leading to positive changes in the impact of OVC
programs. QI approaches applied to OVC programs have enabled organizations,
including local community-based organizations, to provide services more
tailored to the needs of children and vulnerable households, helped
community-level service providers understand more clearly their roles and
responsibilities, increased providers’ satisfaction as they feel more empowered
to meet children’s needs, enabled local nongovernmental organizations to better
support community volunteers and share best practices among themselves, and
promoted sustainability by increasing community participation in meeting the
needs of vulnerable children.
- In 2013, HCI launched the USAID
Care That Counts e-Learning Course for Quality Improvement in Programs for
Vulnerable Children. This course (in English) is designed for staff of
government ministries, international and national nongovernmental organizations,
USAID Mission staff, and others interested in learning more about improving the
quality of programs for vulnerable children or advocating for better programs.
To find out more, please email firstname.lastname@example.org.
Maternal, Newborn, and Child Health; HIV and AIDS; Tuberculosis; Malaria; Reproductive Health and Family Planning; Food and Nutrition; Vulnerable Children and Families
Quality Improvement; Health Systems Strengthening; Health Communication and Behavior Change; Research and Evaluation