USAID study shows effectiveness of collaborative improvement approach for improving health systems

A new study from the USAID Health Care Improvement Project shows that a quality improvement method widely used in the US called collaborative improvement is also effective in low- and middle-income countries.

The study, which was published in BMJ Quality and Safety, involved measuring improvements in health care provided for maternal, newborn and child health, HIV/AIDS care, family planning, and malaria and tuberculosis (TB) diagnosis and treatment in 27 applications in 12 low- and middle income countries. The collaborative improvement approach achieved large increases in provider compliance with evidence-based guidelines in all care areas addressed.

“This multi-country study provides the largest body of evidence yet published on the effectiveness of collaborative improvement in lower and middle-income countries,” said James Heiby, Medical Officer in the USAID Global Health Bureau. “We still have a lot to learn about improving care in these health systems, but the average level of improvement achieved across 27 different settings suggests remarkable potential; much wider use of improvement methodologies like this appears to be feasible.”

The fundamental concept underlying the field of improvement is that a system left unchanged can only be expected to continue to produce the same results. Improvement methodologies emphasize changes in the process of delivering health care, rather than the provision of resources. Most of these changes focus on improving the implementation of high impact, evidence-based interventions. Cost-effectiveness studies show that improvement methodologies can also increase the efficiency of health care delivery.

Collaborative improvement involves a team-based approach to quality improvement. Teams consisting of health care workers in clinics, hospitals, and other levels of the health system work together on common aims to improve particular aspects of the system. The teams test changes in health care processes, share their experiences and then apply the successful changes on a wider scale.

This study shows that many health care processes can be improved without additional resources. Of the 135 time-series charts evaluated for more than 1300 teams, the study found that nearly nine out of ten teams attained performance levels of at least 80%, while two-thirds reached at least 90%. More than half of the teams had a starting performance level of 50% or less.

USAID funded 54 collaboratives in low and middle-income countries from 1998-2008, through the Quality Assurance Project (QAP) and the Health Care Improvement (HCI) Project, both managed by University Research Co., LLC (URC). “It is wonderful to see that URC, with the help of our country partners and colleagues, has made such advances in resource-constrained settings,” said Dr. M. Rashad Massoud, Senior Vice President for the Quality and Performance Institute at URC and Director of the USAID HCI Project.

Teams from 12 countries were involved in the study, representing four distinct regions with different health care systems. They include Benin, Bolivia, Ecuador, Guatemala, Honduras, Nicaragua, Niger, Russia, Rwanda, Tanzania, Uganda, and Vietnam.

Initially funded in 14 countries, the improvement collaborative approach has expanded to include more than 30 countries.

The study, “Effectiveness of collaborative improvement: evidence from 27 applications in 12 less-developed and middle-income countries,” was published in the February online edition of BMJ Quality and Safety. It was co-authored by Lynne Miller Franco, formerly Director of Research and Evaluation for the HCI Project, and Lani Marquez, Knowledge Management and Communication Director for the HCI Project.

About URC
URC, which celebrated its 45th anniversary last year, is a global company dedicated to improving the quality of health care, social services, and health education worldwide. With our non-profit affiliate, the Center for Human Services (CHS), URC manages projects in over 40 countries including the United States. Based in Bethesda, Maryland, URC has about 700 employees around the world.

About HCI
HCI is a USAID-funded project that supports countries in improving the quality and impact of health services. The project assists national and local programs to scale up evidence-based interventions and improve outcomes in child health, maternal and newborn care, HIV/AIDS, tuberculosis, malaria, and reproductive health.