The influence of Continuous Quality Improvement on healthcare quality: A mixed-methods study from Zimbabwe.

In an effort to improve the poor quality of maternal, newborn, and child health services, the Zimbabwe Ministry of Health and Child Care implemented a Continuous Quality Improvement (CQI) pilot in 2016. Health workers and district managers were trained and supported to implement cycles of quality target setting, developing and implementing action plans, and tracking outcomes. The pilot was implemented in district hospitals and primary health centers in five districts as an arm of the performance-based health financing (PBF) program. This study uses mixed methods to estimate the effect of the CQI model on quality of care for various services and to identify factors that enabled or impeded quality improvements. We assessed changes in quality of care for seven services over a two-year implementation period and compared these changes against other PBF districts. We also conducted focus group discussions and in-depth interviews with district and facility-level health workers and managers after implementation to explore enabling and impeding factors affecting program performance. Among the seven services assessed, CQI was associated with quality improvement in primary health centers for two: postnatal care and maternal delivery care. Enabling factors included strengthened leadership, teamwork and joint decision-making at facilities; and supportive supervision. Impeding factors included fragmentation of quality assurance policies; staff shortages and turnover; and gaps in the CQI training. Improvements were limited when considering the full breadth of potential outcomes but arise in certain areas of core focus of the CQI program. In order to see large scale improvement in the quality of healthcare in Zimbabwe, CQI should be seen as one potential tool in a broader health systems quality improvement strategy.

The Challenges of Transition From Donor-Funded Programs: Results From a Theory-Driven Multi-Country Comparative Case Study of Programs in Eastern Europe and Central Asia Supported by the Global Fund.

INTRODUCTION: In the era of declining development assistance for health, transitioning externally funded programs to governments becomes a priority for donors. However, the process requires a careful approach not only to preserve the public health gains that have already been achieved but also to expand on them. In the Eastern Europe and Central Asia region, countries are expected to graduate from support from the Global Fund to Fight AIDS, Tuberculosis and Malaria in or before 2025. We aim to describe transition risks and identify possible means to address them. METHODS: Using a theory-based conceptual framework-Transition Preparedness Assessment of Tuberculosis and HIV/AIDS programs-we investigated transition-related challenges through a health systems lens in 10 countries of the Eastern Europe and Central Asia region during 2015-2017. Study findings were derived from systematic collection of quantitative data on socioeconomic indicators and disease epidemics as well as qualitative data from in-depth interviews with 264 stakeholders. These findings were then compared with other donor transition experiences documented elsewhere. RESULTS: We found numerous common transition challenges, such as poor monitoring of a country's macroeconomic performance along with weakness in estimating financial needs for successful transition; limited political will of governments to replace donor-funded programs; punitive legislation criminalizing certain behaviors and constraining the government's ability to allocate funds and contract civil society organizations essential to providing services for key populations; limited coordination function of governments and weak decision-making power of coordinating mechanisms obscuring the latter's future role; and inadequate function of national procurement and supply chain management systems undermining an uninterrupted supply of quality-assured drugs and commodities. These challenges are compounded by the risks related to health workforce management leading to specialist shortages and/or inadequately skilled and qualified professionals and by limited funding for critical surveillance activities. CONCLUSION: The complex and multidimensional transition process requires a multipronged approach through well-planned collective and coordinated responses from global, bilateral, and national partners in coming years. Other similar transition processes may provide guidance. Although no "one-size-fits-all" approach exists, previous experiences highlight a need for both early planning and monitoring of the transition along several key dimensions. Issues that could threaten the maintenance of health gains include ongoing stigma against key populations; continued heavy reliance on external funding in some countries, especially for preventive services; the institutional viability of the country coordinating mechanisms; and emerging difficulties with procurement of quality drugs at reasonable prices.