USAID Health Care Improvement Project (HCI) | Global


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 collaboratives, job aids, self-assessment, and performance-based incentives—to the context of USAID-assisted countries.

Improvement Collaborative Model


Key Activities

  • 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 services.
  • 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 Health Care Improvement website and related sites aimed at regional audiences in Latin America. 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 Nicaragua.
  • 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 improvement efforts.
  • 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 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..
  • 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.
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