USAID Health Care Improvement Project (HCI)


The Health Care Improvement Project (HCI) was 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 achieved its goal of making measurable gains in the quality of health care as well as improving health workforce management. URC supported 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 successfully developed the capacity of host country health systems to apply modern QI approaches to make essential services better meet the needs of underserved populations. URC improved the efficiency and reduced the costs health care and improved health worker capacity, motivation, and retention. The project built 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, total quality management, improvement collaborations, job aids, self-assessment, and performance-based incentives.



  • HIV/AIDS: Support 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. Support 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): Apply 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), contribute 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. Support 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 services.
  • Orphans and vulnerable children (OVC): Support 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. Develop 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: Strengthen 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: Apply collaborative improvement and other QI approaches to strengthen health worker engagement, productivity, retention, and performance management. Collaborate with the Global Health Workforce Alliance and other partners to develop strategies to improve the effectiveness of community health workers (CHWs) and develop a toolkit to assess the functionality of CHW programs. Develop a framework for improving the quality of in-service training programs to ensure their sustainability, effectiveness, and efficiency. Conduct 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: Support a global knowledge management system to gather and share learning from QI teams and country experiences through the a project website and other related sites aimed at regional audiences in Latin America. Ensure that these sites offer extensive resources on QI methods and approaches for improving health services delivery and 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, support a focused program of research and evaluation related to the spread and institutionalization of best practices and improvement methods. Accelerate learning and results through collaborative improvement, improve the efficiency of QI interventions, adapt QI methods to community-level services, enhance QI team performance, and document the cost-effectiveness and cost implications of QI interventions.
  • Technical leadership: Provide global technical leadership for USAID's initiatives to improve health care by collaborating with other international agencies. Disseminate QI results, tools, and methods to support the strengthening of health systems in USAID-assisted countries.



  • Developed a framework for improving the quality of care for HIV and AIDS patients; focused on coverage of those eligible for ART, retention of patients in care, and improving patients’ clinical outcomes. The framework was applied in Cote d’Ivoire, Tanzania, Uganda, Russia, and Nicaragua.
  • 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.
  • Developed CHW program assessment and improvement matrix. CHW AIM helped 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 improvement efforts.
  • Delivered a web-based knowledge management system that 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 own funds.
  • 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 25%.
  • 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 months.
  • 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.
  • 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.
  • In 2013, launched USAID Care That Counts e-Learning Course for Quality Improvement in Programs for Vulnerable Children. This course was designed for staff of government ministries and anyone interested in learning more about improving the quality of programs for vulnerable children.


Mother and newborn at Malalai Hospital in Kabul, Afghanistan.
Mother and newborn at Malalai Hospital in Kabul, Afghanistan. The birth attendant for this successful outcome was trained by HCI in essential newborn care as part of efforts to improve the quality of obstetric and newborn care. Photo by Annie Clark, URC.
2007 to 2014
US Agency for International Development (USAID)
EnCompass, LLC
FHI 360
Health Research Inc. (HRI)
Initiatives, Inc.
Institute for Healthcare Improvement (IHI)
Johns Hopkins Center for Communication Programs