Integration of Essential Health Services in Burundi Through the Use of the Collaborative Quality Improvement Model

Integration of Essential Quality Health Services in Burundi Improvement through the Use of the Collaborative Quality Stories Improvement Model

Integrated Health October 2018 Project in Burundi Hilaire Ndihokubwayo Roland Kone Bruno Bouchet

IHPB

Acknowledgements We would like to express our sincere thanks to the Burundi Ministry of Public Health and the Fight against AIDS for involving the central, intermediate and local levels in the implementation of the service integration process, as well as their spirit of partnership and collaboration with the IHPB project (Integrated Health Project in Burundi).

This document would not have been produced without the support of the American people through the United States Agency for International Development (USAID) Contract AID- 623-C-14-00001 awarded to FHI 360. The content is the sole responsibility of the authors and does not necessarily reflect the views of USAID or the US Government. As such, we express our deep gratitude to USAID for the financial and technical support provided to FHI 360 through the IHPB project.

Recommended Citation: Ndihokubwayo H., Kone R., & Bouchet B. Integration of Essential Health Services in Burundi through the use of the Collaborative Quality Improvement Model. Quality stories. IHPB project. FHI 360. September 2018.

KIRUNDO Intervention framework of the IHPB project

CIBITOKE MUYINGA The Integrated Health Project in Burundi (IHPB) NGOZI is a project funded by the United States Agency for KAYANZA

International Development (USAID) and implemented BUBANZA KARUZI CANKUZO by FHI 360 (Family Health International) in partnership MURAMVYA with Pathfinder International. BUJUMBURA RUYIGI MWARO GITEGA IHPB aims to help the Government of Burundi, communities and civil society organizations (CSOs) improve population health status in 12 health districts BURURI RUTANA located in the provinces of Karusi, Kayanza, Kirundo and Muyinga.

MAKAMBA The purpose of the project is to expand and integrate essential services to support the fight against HIV/AIDS, improve maternal, newborn and child health (MNCH), combat malaria and strengthen family planning (FP) and reproductive health (RH) services.

The Ministry of Public Health and the Fight against AIDS (MSPLS) is the primary partner involved in every stage of project planning and implementation.

Integration of Essential Health Services in Burundi through the Use of i the Collaborative Quality Improvement Model Table of contents

Acknowledgements...... i

Intervention framework of the IHPB project...... i

Acronyms and abbreviations...... iv

Executive summary...... 3

Introduction...... 5

Background and socio-economic indicators...... 5

Health system organizational and institutional framework...... 5

Health and epidemiological context...... 5

Baseline situation and opportunities for improvement...... 7

Identification of opportunities for integration...... 7

Collaborative Quality Improvement Model...... 8

Implementation timeline for the collaborative integration of essential services in Burundi ...... 10

Preparation phase...... 10

Demonstration phase...... 11

Extension/scaling-up phase...... 12

Results of integration efforts from each province ...... 13

Integration of FP into MCH in Karusi health province ...... 13

1. Project rationale and expected benefits...... 13

2. Goal and objectives...... 13

3. Results...... 13

ii Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Contribution of FP services integration in increasing contraceptive coverage in Karusi province...... 17

Improved integration of early ANC, SGBV care and HIV testing in curative services in Kirundo health province ...... 18

1. Project rationale and expected benefits ...... 18

2. Project goal ...... 18

3. Results...... 18

Improved integration of FP into MCH and HIV care services in Kayanza health province...... 21

1. Project rationale and expected benefits...... 21

2. Project goal/objectives...... 21

3. Results...... 21

Improving the integration of Malaria prevention services in Muyinga health province ...... 24

1. Project rationale and expected benefits ...... 24

2. Project goal...... 24

3. Results...... 24

Lessons learned from piloting activities of improving service integration ...... 26

On using the Collaborative Quality Improvement Model ...... 26

Conclusion...... 30

Annexes...... 31

Annex 1: List of HFs involved in the demonstration phase...... 31

Annex 2: Expanded collective package of changes and their implementation activities...... 32

Integration of Essential Health Services in Burundi through the Use of iii the Collaborative Quality Improvement Model Acronyms and abbreviations

AIDS Acquired Immune Deficiency Syndrome

AMC Average Monthly Consumption

ANC Antenatal Care Consultation

ARV Antiretroviral (Antiretroviral drugs)

CC Curative Consultation

CHW Community Health Worker

CP change package

CSO Civil Society Organization

DH District Hospital

DMO District Medical Officer

DMPA Depot - Medroxyprogesterone Acetate

FHI 360 Family Health International

FOM IHPB Field Office Manager

FP Family Planning

FPC Family Planning Counseling

GATHER Greet, Ask, Tell, Help, Explain, Return

GB Government of Burundi

HC Health Center

HD Hospital Director

HDO Health District Office

HE/IEC Health Education (Health IEC)

HF Health Facility

HR Human Resources

HIS Health Information System iv Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model HPO Health Province Office

HISM Health Information System Management

HIV Human immunodeficiency virus

IHPB Integrated Health Project in Burundi

IPT Intermittent Preventive Treatment of malaria for pregnant women

IUD Intra-uterine device

LLIN Long-lasting Insecticidal Nets

LS Learning Session

MCH Maternal and Child Health

MH Maternal Health

MPA Minimum Package of Activities

MSPLS Ministry of Public Health and the Fight against AIDS

MUAC Mid-upper Circumference

OTS Outpatient treatment service

PDSA Plan, Do, Study, Act (Plan-Do-Study-Act cycle of innovation)

MCSPEC Medical care and support

HMM Home-based management of malaria

PBF Performance-based financing

PEP (HIV) Post-exposure Prophylaxis

PHO Provincial Health Office

PIT Provider-Initiated HIV Testing

PLHIV People Living with HIV

PMO Provincial Medical Officer

PMTCT Prevention of mother-to-child transmission of HIV/AIDS

PNC Postnatal Consultation

Integration of Essential Health Services in Burundi through the Use of 1 the Collaborative Quality Improvement Model National Program to Combat AIDS and PNLS/IST Sexually Transmitted Infections (STIs) Program PNSR National Reproductive Health Program

PV Minutes, « Procès-Verbal »

QI Quality Improvement

QIT Quality Improvement Team

RBP+ Burundian Network of People Living with HIV

RUTF Ready-to-use Therapeutic Food (RUTF)

SGBV Sexual and Gender based Violence

SHC Strategies for handling complaints

SP Sulphadoxine Pyrimethamine

SWAA Society of Women against AIDS in Africa

TOR Terms of Reference

USAID United States Agency for International Development

USG United States Government

VCT Voluntary Counseling and Testing

WA Weeks of Amenorrhea

2 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Executive summary The IHPB project (Integrated Health Project in Burundi), funded by USAID and implemented by FHI 360 and Pathfinder International, aims to strengthen critical care and service systems in HIV/AIDS, maternal and child health, family planning and reproductive health and malaria. Service integration is a critical strategic component in achieving project objectives of improving population health status through increased care coverage and service quality.

The strategy for the integration of essential services in Burundi was designed during a workshop organized by the Ministry of Public Health and the Fight against AIDS (MSPLS) and IHPB in August 2014, with participation from actors (PMO, DMO, and hospital directors) in the target provinces. During this workshop, the participants identified the following opportunities for service integration in each province: • Karusi: Improve and integrate FP into maternal and child health services; • Kirundo: Improve and integrate a package of services (ANC, early ANC, SGBV, malnutrition, HIV testing) into curative consultations; • Kayanza: Improve and integrate FP into maternal health services and PLHIV care; • Muyinga: Integrate malaria prevention into ANC services.

During this workshop, participants also approved the use of the Collaborative Quality Improvement Model to facilitate the implementation of required changes for successful integration and service quality improvement.

In each province, quality improvement teams (QITs) were put in place, improvement indicators were measured monthly in a database that automatically generated performance charts, and changes in care delivery were tested. The QITs met regularly to identify a package of best practices that was tested in 52 HFs and then expanded to 165 HFs. From June 2015 to December 2017, the following results were obtained:

In Karusi, the proportion of women who brought their children in for immunization and accepted a contraceptive method increased from 0 to 6%, while the proportion of women who gave birth in a maternity clinic and received the contraceptive method increased from 4% to 36%. At the same time, the proportion of women referred by CHWs who arrived at health centers (HCs) for adherence to FP methods increased from 54% to 91%.

In Kirundo, out of 11,402 women of childbearing age who attended curative services and received a routine pregnancy screening, 9,185 or 81% had a pregnancy of less than 12 WA

Integration of Essential Health Services in Burundi through the Use of 3 the Collaborative Quality Improvement Model and 79% benefited from early ANC the same day. Integration of HIV serologic screening in 104,602 at-risk patients contributed to the detection of 2,142 (2%) positive cases. Finally, out of a total of 284 cases of SGBV victims received in curative consultations, 266 or 94%, received post-exposure prophylaxis against HIV within 72 hours in the same health facility (HF) and on the same day.

In Kayanza, among 39,402 women seen in postnatal consultations (PNC), 8,729 (22%) were put on contraceptive methods. Among the active file of HIV-positive women of childbearing age, 55% received counseling services and began to use contraceptive methods.

In Muyinga, the proportion of pregnant women seen in ANC1 who received LLINs increased from 30% to 100% and the proportion of pregnant women seen in ANC3 who received the second dose of IPT increased from 0% to 68%.

The main lessons learned from this experience with the integration process, the use of the Collaborative Quality Improvement Model, as well as the effect of the implemented changes should enable other provinces to develop their own strategy for improving health services and ensuring sustainability of achievements through the MSPLS.

4 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Introduction The Integrated Health Project in Burundi) (IHPB), funded by USAID, works closely with the Government of Burundi (GB), civil society organizations (CSOs), communities and other development partners to strengthen the health system at the household, community, health facility and health district levels in four provinces: Karusi, Kayanza, Kirundo and Muyinga.

The project, implemented by FHI 360 and Pathfinder International, aims to strengthen essential care and service systems in HIV/AIDS, maternal and child health, family planning and reproductive health and malaria. Service integration is a key strategic component in achieving project objectives to improve population health status through increased care coverage and service quality.

Background and socio-economic indicators Burundi is a landlocked country with a population of 10,395,951 inhabitants. The socio- economic development indicators are summarized in Table 1.

Table 1: Burundi’s socio-economic development indicators Indicators Results/Year (references) Human Development Index 0.400; Burundi ranks 184/187 (UNDP, 2017) GDP per capita 2,976 USD (UNDP, 2017) Human poverty index (HPI) (% of people living on 81.3% (UNDP, 2015) less than 1.25 USD per day).

Health system organizational and institutional framework Burundi's health pyramid is comprised of three levels: central, intermediate and local. • The central level is responsible for health policy, strategic planning, activities coordination, resource mobilization and allocation and performance monitoring; • The intermediate level consists of 18 Provincial Health Offices (PHOs) that coordinate activities within their respective provinces and provide support to the health districts; • The local level is made up of 46 health districts, each managed by a district management team (DMT), 68 district hospitals (DHs) and 822 health centers (HCs). The district is the operational unit of the health care system. It covers the community level, the HCs and the DH.

Integration of Essential Health Services in Burundi through the Use of 5 the Collaborative Quality Improvement Model Health and epidemiological context The Government of Burundi (GB), with the support of the US Government and other partners, has achieved considerable progress in the health sector in terms of decentralization and service expansion. Despite this, the health situation remains a matter of concern and is marked by the prevalence of many communicable and non- communicable diseases: malaria, acute respiratory infections, diarrheal diseases, malnutrition, HIV/AIDS and tuberculosis are the main causes of morbidity and mortality. Table 2 presents the main epidemiological data available at the start of the project.

Table 2: Burundi National Epidemiological Health Data at Project Start-up Indicators Results/Year Results/Year (2014) (references) Reproductive Health and Family Planning Fertility rate/Total fertility rate (TFR) 6.4 : DHS 2010 5,5 : DHS 2017 Contraceptive prevalence rate 25% : PNSR 2012 29 % : DHS 2017 Use of contraceptive methods. 18% : DHS 2010 23% : DHS 2017 Unmet need in FP 31% : DHS 2010 30 % : DHS 2017 Maternal, Neonatal and Child Health Maternal mortality (deaths per 100,000 500 : DHS 2010 590 : DHS 2017 live births) Neonatal Mortality 36‰ : IGME-2013 23‰ : DHS 2017 Infant mortality (under 5 years old) 59‰ : DHS 2010 47‰ : DHS 2017 Coverage rate for ANC4 33% : DHS 2010 79% : DHS 2017 Malaria Prevalence of malaria in children 17,3% : MIS-2012 26,8% GE and 37.9% (TDR) Incidence of malaria 32,7% : DHS 2010 89.9% : DHS 2017 Malaria-specific mortality rate 34,07‰ PNILP 64‰ PNILP 2012 (deaths per 1,000) 2010 HIV/AIDS Prevalence rate in women aged 15-49 1,7% : DHS 2010 1.2% DHS 2017 Prevalence rate in men aged 15-49 1% : DHS 2010 0.8% DHS 2017

6 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Baseline situation and opportunities for improvement The overarching objective of the IHPB project is to improve the delivery of The intention behind the objective for quality integrated services at the health integration is to provide patients with a facility (HF) and community levels in four package of services beyond the principal provinces. Table 3 shows the project’s scale. demand that motivates visits (to the HF) and thereby reduce missed opportunities Identification of opportunities to satisfy unmet needs, therefore making for integration the system more efficient and preventing the need for repeated patient visits. In this To identify appropriate ("smart") project, service integration was defined on integration opportunities, the IHPB a scale ranging from the provision of sev- project organized a workshop in eral services provided on the same day by Bujumbura on August 2014 with all the same provider to referral to a different stakeholders: MSPLS representatives, provider on the same day and in the same ministry program officers, provincial and health facility. district doctors (health officers), USAID, CSOs and development partners. The workshop’s main objective was to prioritize integration opportunities in the provinces supported by the IHPB project and to plan their implementation pilot phase in a sample of 52 HFs. Table 4 presents the identified opportunities by province.

Table 3: Number of HFs per province and district of the IHPB project target area Provinces Districts Hospitals Health centers (HCs) Karusi 2 2 35 Kayanza 3 3 45 Kirundo 4 2 50 Muyinga 3 3 51 Total 12 10 181

Table 4: Integration opportunities per province Provinces Integration Opportunities Karusi Integration of FP into MCH services Kirundo Integration of early ANC, HIV, and SGBV into curative consultation services Kayanza Integration of FP into MCH and HIV care services Muyinga Integration of the malaria prevention package into ANC services

Integration of Essential Health Services in Burundi through the Use of 7 the Collaborative Quality Improvement Model Following the workshop, meetings involving field actors (PMOs, DMOs, HDs, PHO and HDO supervisors, HIS managers), were held in each province to develop and sign a charter for health services improvement and integration. A charter is a reference document that provides a roadmap for the implementation of the improvement process. The charter is structured around the elements of the Collaborative Quality Improvement Model described below.

Collaborative Quality Improvement Model Health services integration requires implementing changes in many functions and tasks within the HF team, such as the organization of care, provider skills, patient referral, communication between providers, working hours, task distribution and introduction of new tools and work/job aids.

At the start of such an effort, it is difficult to know which changes are necessary, feasible and effective. It was therefore rational for IHPB to select an improvement model that relies on testing changes by dispersed but networked teams. The improvement model based on the PDSA cycle (see Figure 1) was selected so each team could test changes specific to their context.

Given the large number of HFs, managing this effort required a phased, gradual model, with a small-scale demonstration phase, then scaled up to all HFs based on results of the tested changes. For example, the Collaborative Quality Improvement Model was chosen to manage this improvement effort. These two models and their interaction are described below.

The Collaborative Quality Improvement Model (also known as “the Collaborative”) has been designed to manage a structured, large-scale improvement effort that involves many teams aiming to achieve the same result in a well-defined population or geographic area. A Collaborative accelerates the extension and sustainability of improvements in a system of care and services, over a period that varies according to the size and complexity of the project. This innovative model, developed by the “Institute for Healthcare Improvement,”1 has 7 features/components: 1. Improvement goal and objectives shared by all units involved (HFs in this case); 2. A common improvement monitoring system based on indicators collected monthly and interpreted on run charts;

1 The Breakthrough Series: Collaborative Model to Achieve Breakthroughs in Improvement Actions by IHI. Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138. www.ihi.org

8 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model 3. An operational structure organized around teams with 5 specific roles and responsibilities: testing changes by Quality Improvement Teams (QITs); Collaborative management (management of the collaborative model) by district; strategic leadership by program decision-makers and experts; expertise in Quality Improvement (QI); and expertise (appropriate skills) in the content of care and services to be improved; 4. A package of changes, that is a combination of service standards and service organization best practices to benefit service delivery improvement; 5. A coaching system to support QITs in implementing the package of changes and assessing/measuring their effects; 6. An improvement model centered on the identification and testing of changes and their impact during action periods, i.e. the PDSA cycle; 7. Learning sessions during which QITs share their experiences in the implementation and the results of the tested changes, in order to define a final package of changes.

A Collaborative can be described in 3 phases: • The preparation phase,during which the first five elements are conducted; • The implementation (or demonstration) phase, where the action periods (change tests) alternate with the learning sessions to assess the effects of the changes on the improvement objectives; • The extension (or scaling-up) phase, where best practices (systemic changes that have produced the expected improvements) are replicated in other health care structures, Figure 1: Quality Improvement Model and sometimes at the national level. FHI Quality Improvement Model Each QIT uses a generic (quality) improvement What are we trying 2 I. Identify the model adopted by FHI 360, shown in Figure 1. to accomplish? improvement aim/objectives This model focuses on testing systemic changes How will we know a change II. Develop the is an improvement? according to the PDSA cycle. If a change produces improvement measurement an improvement, it is maintained. If the change system

What change can we make that III. Generate ideas does not produce the expected improvement, it is will result in improvement? removed and another change is tested. for changes

ACT PLAN The principal steps are: IV. Test/implement system changes • Identify a goal and explicit objectives STUDY DO for improvement (what are we trying to V. Sustain and spread the new system 2 Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Source: GL Langley, KM Nolan, TW Nolan, CL Norman, and LP Provost, The Improvement Guide: A Practical Approach to Enhancing Organizational Performance Improvement Guide: A Practical Approach to Enhancing Organi- (San Francisco: Jossey-Bass, 1996). zational Performance. 2009.

Integration of Essential Health Services in Burundi through the Use of 9 the Collaborative Quality Improvement Model improve?) that express, in measurable terms, a benefit for the target population of the project. • Develop the improvement measurement system (how shall we know if a change is an improvement?). The QIT frequently collects a few indicators, so that the change’s effect is quickly identified through the run chart analysis. • Generate ideas for changes (what changes can we put in place that will produce an improvement?). Using brainstorming, benchmarking and a list of change concepts, stakeholders suggest ideas for changes. • Test/Implement changes (with the PDSA). The changes are introduced, and their effects are assessed against the improvement objectives. This generic model is integrated into the Collaborative; the objectives and measures are the same for all the teams, but the nature of the changes tested (step 3) may vary according to the team’s context.

Implementation timeline for the collaborative integration of essential services in Burundi The three phases of theCollaborative took place between May 2014 and June 2018.

Preparation phase This phase ran from May 2014 to March 2015. It was marked by a baseline assessment through a qualitative survey of services provided by HFs, coach training modules that were adapted and updated; integration charters that were finalized, validated, and signed in the provinces, orientation workshops for key actors on the implementation of the improvement process; establishment of QITs and the monitoring system, and training of coaches and project staff.

Stakeholder orientation in each province In close collaboration with the national reproductive health and AIDS programs (PNSR and PNLS/IST) of the MSPLS, the IHPB project organized an orientation workshop in each province on the integration process and service quality improvement for HFs selected during the demonstration phase, HDO and PHO supervisors, as well as district and provincial health directors. During the workshop, IHPB informed participants on QI principles and models and defined the provincial management structure of the Collaborative.

10 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Establishment of QITs The managers (in-charge) of the pilot HCs were oriented on QIT establishment in their respective facilities and received work/job aids on QIT functionality: QIT composition scheme; Management of meetings (how to prepare and facilitate a meeting); Developing meeting minutes; Follow-up sheet of decisions made by the team; Tracking QIT functionality in sites; Table for planning and meeting follow-up; Improvement plan and monitoring tools. Establishment of the coaching system To build a QIT coaching system, the project trained 24 district supervisors (two per district) on coaching techniques: 1) QI Model; 2) QIT establishment and functionality; 3) Identifying and testing an idea for change; 4) Collaborative approach, and 5) Coach roles and activities.

Training of the IHPB project staff IHPB shared knowledge on the improvement model and collaborative approach to harmonize understanding among project technical staff so they can monitor and coach the QATs during supervisory visits.

Establishment of an indicator tracking plan An Excel database was designed to track the improvement indicators included in the charters and adapted to each province’s specific integration objectives, with monthly measurement by the QITs.

Demonstration phase This phase lasted 18 months, from June 2015 to December 2016. During this phase, QITs are supported through regular coaching visits and organized learning sessions.

Organization of joint coaching visits The 1st joint coaching visits (districts/IHPB) were organized monthly for three months to evaluate the QITs’ work and provide technical assistance on the model’s application. During these visits, the coaches helped the QITs build their initial process chart, identify the problem stages (bottlenecks), their root causes and propose local solutions, which are formulated as ideas for changes that are tested during the visit.

Organization of learning sessions During the demonstration phase, each province held three learning sessions, every three to five months. Each session brought together the QIT president and one member per site, the coaches, the HDO, PHO, and HIS managers, the PMOs and DMOs, and the provincial project staff. Each team presents the ideas for changes that are being tested, the results,

Integration of Essential Health Services in Burundi through the Use of 11 the Collaborative Quality Improvement Model problems, and lessons learned. The session agenda advances according to the progress made/achieved by the teams: at the beginning, the focus is on the improvement processes and progresses towards the interpretation of results at the 2nd session.

Annex 1 provides a list of the HFs selected in the demonstration phase.

Extension/scaling-up phase This phase took place in two stages: a) an intraprovincial extension to all the HFs, from January to December 2017; and (b) an interprovincial replication of results of four integration topics from January to September 2018.

The intraprovincial extension started in each province by reviewing changes that were proven effective and feasible in pilot sites, in order to develop the change package (CP). The teams, their coaches and provincial authorities have adopted the specific CP of their province and planned its extension into a charter. The intra-provincial extension was conducted in two successive waves considering the realities of each district and available resources. The first wave consisted of organizing experience-sharing site visits of the new extension sites around the pilot sites. The second wave consisted of pilot sites coaching the extension sites in order to introduce the CP, and provide and explain the implementation tools of the changes. For this second wave, the extension agents were staff from the best teams during the demonstration phase.

The interprovincial extension started with a dissemination workshop bringing together the Department of healthcare supply and demand, the 4 Provincial Health Officers/ Directors and 12 DMOs, coaches, district supervisors, and district HIS managers and extension agents. During this workshop, best practices from each province were combined into a collective package of best practices/changes that were amended and validated. The interprovincial extension of this collective package of changes took place during joint coaching visits by extension agents, district coaches, and IHPB staff. The monitoring plan and the Excel indicator database were also distributed to all teams.

Table 5: Number of HFs Covered by the Integrated Service QI Approach in Four Provinces Province Pilot Sites Extension Sites Total Muyinga 9 37 46 Karusi 11 21 32 Kirundo 17 33 50 Kayanza 15 22 37 Total 52 113 165

12 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Results of integration efforts from each province Integration of FP into MCH in Karusi health province 1. Project rationale and expected benefits The decision for the integration project was guided by a low contraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal and child health (MCH) services therefore offers an opportunity to increase access to and use of contraception.

2. Goal and objectives Increase the contraceptive coverage rate through integrating FP services into immunization and post-natal consultation (PNC) services.

Table 6: Improvement objectives and monitoring indicators Objectives Indicators Reduce missed opportunities to offer FP % of women who bring children for immunization counseling to any woman who brings her child to services and who received FP counseling. the immunization service/unit and any woman % of women seen in PNC and who received FP seen in post-natal consultation (PNC). counseling. Reduce missed opportunities to provide FP % of women who bring children in for methods to women who bring their children immunization services who received FP methods in for immunization services and women seen % of women seen in PNC who received FP in PNC. methods. Reduce missed opportunities to provide FP % of hospitalized women who received FP services to women admitted to (hospitalized in) counseling. maternity wards and those who have given birth, % of women who gave birth in maternity wards particularly through caesarean deliveries. and who received FP methods. Increase the demand for FP methods at the % of women referred by CHWs to HCs for FP community level. counseling and who received a FP method.

3. Results Objective: Reduce missed opportunities to offer family planning counseling (FPC) to any woman who brings her child to the immunization service/unit.

Integration of Essential Health Services in Burundi through the Use of 13 the Collaborative Quality Improvement Model

The decision for the integration project was guided by a low contraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal and child health (MCH) services therefore offers an opportunity to increase access to and use of contraception.

2. Goal and objectives Increase the contraceptive coverage rate through integrating FP services into immunization and post- natal consultation (PNC) services.

Table 6: Improvement objectives and monitoring indicators Objectives Indicators Reduce missed opportunities to offer FP % of women who bring children for counseling to any woman who brings her child to immunization services and who received FP the immunization service/unit and any woman counseling. seen in post-natal consultation (PNC). % of women seen in PNC and who received FP counseling. Reduce missed opportunities to provide FP % of women who bring children in for methods to women who bring their children in for immunization services who received FP immunization services and women seen in PNC. methods % of women seen in PNC who received FP methods. Reduce missed opportunities to provide FP % of hospitalized women who received FP services to women admitted to (hospitalized in) counseling. The33.. decisionRRééssuullttaa tfortss the integration project was guided by a low contraceptive coverage rate of 24%, while maternity wards and those who have given birth, % of women who gave birth in maternity wards the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is particularly through caesarean deliveries. and who received FP methods. OObbjanjeecc ttindicationiiff :: RRéédduuiirre eof llee sas ohighoppppoo rraterttuunni itoftéés sservice mmaannqquu éuseéeess ddby’’oo fmothers.fffrriirr uunn CCPP FIntegratingF àà ttoouuttee ffee mmFPmm intoee qquu immunizationii aammèènnee ssoonn een nandffaannt tmaternal ddaannss Increase the demand for FP methods at the % of women referred by CHWs to HCs for FP llee ssandeerrvviic cechilde ddee vvhealthaacccciinnaat ti(MCH)ioonn.. services therefore offers an opportunity to increase access to and use of contraceptioncommunity level. . counseling and who received a FP method. GraphiqueGraphique 11 :: PourcentagePourcentage desdes femmesfemmes quiqui amènentamènent lesles enfantsenfants dansdans lesles servicesservices dede vaccinationvaccination àà quiqui 3. Results onon aa donnédonné2. G leslesoa conseilsconseilsl and ob surjsurect lailav e PPsFF dansdans lesles sitessites pilotespilotes etet d’extensiond’extension dede JuinJuin 20152015 àà DécembreDécembre 20172017 dansdans Figure 1: Percentage of women who bring children in for immunization services who were given lala FPprovinceprovinceIncrease counseling de dethe KarusiKarusi coin pilotntraceptive and extension coverage sites rate from through June 2015 integrating to December FP services 2017 in into Karusi immunization province and post- .. natalObjec consultationtive: Reduce m(PNC)issed services opportu. n ities to offer family planning counseling (FPC) to any woman who brin100gs her child to the immunization service/unit. % 100 % Table 6: Improvement objectives and monitoring indicators Figure8080 1: Percentage of women who bring children in for immunization services who were given FP counselingObjectives in pilot and extension sites from June In2015dicat otors December 2017 in Karusi province. Reduce6060 missed opportunities to offer FP % of women who bring children for counseling to any woman who brings her child to immunization services and who received FP 1004040 L.S.2 the immunization service/unit and any womanL.S.2 counseling. 80 L.S.1 seen20 in post-natal consultationL.S.1 (PNC). % of women seen in PNC and who received FP 6020 changes s changes counseling. 40 e ExtensionExtension

00 g Reduce20 missedn opportunities to provide FP % of women who bring children in for JJ JJ a AA SS OO NN DD JJ FF MM AA MM JJ JJ AA SS OO NN DD JJ FF MM AA MM JJ JJ AA SS OO NN DD methods0 to h women who bring their children in for

C immunization services who received FP 2015 2016 2017 immunization services2015 and women seen in2016 PNC. methods 2017 SitesSitesPilo PilotesPilotest sites SitesESitesx%t e ofn d'Extensiond'Extensions iowomenn sites seen in PNC who received FP methods. 2015 2016 2017 FromReduce June missed2015 to opportunitiesDec. 2017, 156,021 to provide women FP brought % of theirhospitalized children women in for vaccination, who received FP De Fromjuin 2015 June à 2015 Déc.2017, to Dec.2017, 156.021 156,021femmes ontwomen amené brought leurs enfantstheir children pour la invaccination for vaccinat dontion, 143 of .172whom Deof juin serviceswhom 2015 143,172 toà D womenéc.2017, (92%) admitted 156. received021 femmesto (hospitalizedFP counseling. ont amené in) Thisleurscounseling. enfantsrate has po rapidlyur la vaccination increased dontsince 143 .172 (92%)143,172 ont (92%)été conseillées received FP sur counseling la PF. Ce. This taux rate a hasconnu rapidly un increasedrythme croi sincessant the initiationdepuis le of début the changes, des (92%)thematernity initiationont été wardsconseillées of the and changes, those sur lawho from PF. have Ce73% giventaux to 89% abirth, connu and % maintainedun of womenrythme who atcroi 100% gavessant birth throughoutdepuis in maternity le début the wards des changementfrom 73%s to, passant 89% and de maintained 73% à 89 % at pour 100% se throughoutmaintenir à the 100% extension durant toutephase la. phase d’extension. changementextensionparticularlys phase., passant through de c a73%esarean à 89 deliveries.% pour se maintenir àand 100% who durant received toute FP la methods phase d’. extension. Increase the demand for FP methods at the % of women referred by CHWs to HCs for FP OObbjjeeccttiiff :: RRéédduuiirree lleess ooppppoorrttuunniittééss mmaannqquuééeess dd’’ooffffrriirr lleess mméétthhooddeess PPFF àà ttoouuttee ffeemmmmee qquuii aammèènnee ssoonn Objective:community Reduce level .missed opportunities to offer FP counselingmethods to andany whowoman received who abrings FP method her . eennffaanntt ddaannss llee sseerrvviiccee ddee vvaacccciinnaattiioonn.. child to the immunization service/unit. 15 Graphique3. R2e s: uPourcentagelts de femmes qui amènent des enfants dans le service de vaccination Graphique 2 : Pourcentage de femmes qui amènent des enfants dans le service de vaccination conseilléesconseilléesFigure 2: Percentagesur sur lala PFPF quiqui of acceptentacceptent women bringing lala méthodeméthode children dansdans to la lathe provinceprovince immunization sanitairesanitaire unit dede who KarusiKarusi received FP counselingObjective: and Red whouce macceptedissed op ap FPort umethodnities t oin o Karusiffer fa Healthmily pl aProvince.nning counseling (FPC) to any woman who % % brin1212gs her child to the immunization service/unit.

Figure1010 1: Percentage of women who bring children in for immunization services who were given FP counseling88 in pilot and extension sites from June 2015 to December 2017 in Karusi province.

66 100 4 804 L.S.2 L.S.2 L.S.1 6022 L.S.1 s

40 e Extension g Extension changes n 2000 changes a

0 JJ JJ h AA SS OO NN DD JJ FF MM AA MM JJ JJ AA SS OO NN DD JJ FF MM AA MM JJ JJ AA SS OO NN DD C 20152015 20162016 20172017 PSitesilot pilotessites ESitesxten d'extensionsion sites Sites pilotes Sites d'extension 2015 2016 2017 From June 2015 to Dec.2017, 156,021 women brought their children in for vaccination, of whom LLee taux143,172taux moyenmoyen (92%) dede received nouvellesnouvelles FP acceptantescounselingacceptantes. This desdes rate méthodesméthodes has rapidly contraceptivescontraceptives increased since estest dethede 6 6initiation %.%. OnOn observe observeof the changes, uneune progressionprogressionfrom 73% croissantetocroissante 89% and après aprèsmaintained chaquechaque at session session100% throughout d’d’apprentissageapprentissage the extension quiqui atteintatteint phase 11%11%. enen maimai 20172017 pourpour sese stabiliserstabiliser autourautour ddee 7%7% durantdurant lala phasephase d’d’extension.extension. 14 Integration of Essential Health Services in Burundi through

the Use of the Collaborative Quality Improvement Model 1616 15

The decision for the integration project was guided by a low contraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal and child health (MCH) services therefore offers an opportunity to increase access to and use of contraception.

2. Goal and objectives Increase the contraceptive coverage rate through integrating FP services into immunization and post- natal consultation (PNC) services.

immunizationObjective: Reduce services missed and womenopportunities seen in to PNC provide. FP counseling (FPC) to any woman seen methods in PNC. % of women seen in PNC who received FP Typically,ecti éd uwomenire les o useppo rpostnataltunités ma consultationnquées d’or i(PNC)r unmethod services à tos.u te onlyemm ewhen ue e theyn ohave Reducepostpartum missed issues. opportunities To increase tothe provideuse of PNC FP services,% of hospitalized providers organizewomen who BCG received FP D’haitude les emmes ne consultent les serices de o que lorsqu’elles ont des prolèmes en post services to women admitted to (hospitalized in) counseling. partumvaccination Pour accroitre and PNC l’utilisation services des on sericesthe same de day o and les refer prestataires women oranisentto PNC where la accination they pour maternity wards and those who have given birth, % of women who gave birth in maternity wards le receive et les postnatal serices carede o and leindividual mme our FPC. et orientent As a result, les emmesfrom June en o2015 oto Decemberelles énéici 2017,ent d es particularly through caesarean deliveries. and who received FP methods. soins33,760 post womennatals et were du seen indiiduel in PNC insi services, depuis of uin whom 01 31,602 à écemre or 94%, 01 received 0 emmes ont été Increase the demand for FP methods at the % of women referred by CHWs to HCs for FP reuesFP counseling. dans les serices de o dont 10 soit % ont reu un conseil en community level. counseling and who received a FP method.

ecti éduire les opportunités manquées d’orir les méthodes de à toute emme ue en o Objective:3. Resu Reducelts missed opportunities to provide FP methods to every woman seen in PNC. pie oente de ees ees en o onseilles po l et i eptent les OFigurebjectiv e3:: PercentageReduce mis sofe dwomen oppor treceivingunities to PNC offe whor fam receiveily plan FPnin counselingg counselin andg (F whoPC) t oaccept any w FPom methodsan who todesin pilot and PF dansextension les sites sites. pilotes et d’extension. brings her child to the immunization service/unit.

% 0 Figure 1: Percentage of women who bring children in for immunization services who were given FP hanes counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. 0 1 100 8010 1 60 s 40 e Extension

0 g

20 n

a 0 h C 01 01 01

ites pilotes sites dtension Pilot sites Extension sites e tau moen de 2015nouelles acceptantes de méthode2016 s de ues en o est de 1%2017 sur 0 mois n The average monthly rate of accepting new FP methods seen in PNC is 12% over 30 noteFrom éalement June 2015 une to netteDec.2017, amélioration 156,021 en women deu temps brought apr theirès la childrendeuxième in SA for et vaccinat le débution, d’etension of whom o143,172months. ce tau (92%) est Note passé received a clear respectiement FP improvement counseling de. This in % tworate à 1 stages:has % rapidlyuin after et increased écemre the second since 01 theLS pourand initiation theatteindre start of the ofun changes,the pic de %fromextension en 73% eptemre to where89% and 01 this maintained esrate sites rose pilotes atfrom 100% affichent9% throughout to 17% une (June meilleure the extensionand Dec.performance phase2016),. respectively, que les sites d’ toetension reach iena peak que ces of 23%derniers in September montrent une 2017. proression Pilot sites plus show rapide better performance than extension sites, although the latter show a faster progression. ecti Réduire les occasions manquées d’offrir les services de au emmes hospitalisées en maternité et celles aant accouché en particulier les césarisées 15 urant les 1 mois qu’a duré la phase de démonstration emmes ont été admises en maternité

à l’hpital de uhia es prestataires saisissent cette opportunité pour orir un en couples insi emmes soit 1 % ont accepté une méthode de le plus souent le

nersement l’intégration des serices de che les emmes amenant les enants dans les serices de consultation curaties de moins de cinq ans ou hospitalisés en pédiatrie durant la mme période a démontréIntegration que lesof Essentialemmes aant Health des Services enants inmalades Burundi sont through primordialement the Use of préoccupé par l’état15 de santé de leurs enants et ne sont pas récepties pour l’adhésion spontanée au méthodes de le the Collaborative Quality Improvement Model tau de nouelles acceptantes est as autour de 1%

ecti umenter l’accessibilité des services de PF dans la communauté. pie oente des ees es p des et i ient po dsion ne tode de dns les sites pilotes et d’extension.

The decision for the integration project was guided by a low contraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal and child health (MCH) services therefore offers an opportunity to increase access to and use of contraception.

2. Goal and objectives Increase the contraceptive coverage rate through integrating FP services into immunization and post- natal consultation (PNC) services.

Objective: Increase the accessibility of FP services in the community. 3. Results

Figure 4: Percentage of women referred by CHWs who come to HCs to receive/initiate a FP method O inbj ethecti vpilote: Re andduc extensione missed osites.pportunities to offer family planning counseling (FPC) to any woman who brings her child to the immunization service/unit.

Figure 1: Percentage of women who bring children in for immunization services who were given FP counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province.

100 80 L.S.2 60 L.S.1 s

40 e Extension g 20 n a A S D F A A S D F A A S D 0 h C PiSiteslot s iPilotestes ExtenSitession d`Extansionsites

2015 2016 2017 ’effort d’A pour accrotre l’intégration de la PF au niveau de la communauté a abouti un FromThe JuneQI effort2015 toto Dec.2017,increase FP156,021 integration women at broughtthe community their children level hasin forbeen vaccinat successfulion, of with whom 143,172pourcentage (92%) receivedmoen de FP counseling des références. This rate effectivehas rapidlys mises increased sous sinceméthodes the initiation PF dans of les the sites changes, pilotes contrean average percentage dans les sites of 83% d’extension. of actual referrals’intégration using de FPla PF methods dans le incadre pilot du sites, PAD versus est une from 73% to 89% and maintained at 100% throughout the extension phase. pratique97% in extension qui a contribué sites. Integrating la réussite FPde intocette HMM approche. is a practicehaque femme that has qui contributed amène son toenfant the pour unesuccess prise of en this charge approach. de la fièvre Each re womanoit un whoPF et brings un billet her de child référence in for feverpour allertreatment prendre receives la méthode auFPC DS and o a elle referral est reue (document) en priorité to. take to the HC where she is promptly received for

provision of a FP method. 15

16 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model

Contribution of FP services integration in increasing contraceptive coverage in Karusi province After 18 months of the demonstration phase (from July 2015 to December 2016), we compared QI pilot sites with non-pilot sites to assess the effects of integrating FP services.

Figure 5: Contribution of integration to IUD coverage (Source: HIS HPO Karusi).

400 376 • Figure 5 shows that the number of IUD users 350 337

300 was 3 times higher in the demonstration sites

250 (337 against 98) in 2015

200 • In 2016, the number of new IUD users was 150 8 times higher in demonstration sites (376) 98 100 than in other sites (47) 47 50

0 Pilot Sites Non-pilot Sites

Acceptors - IUD 2015 Acceptors - IUD 2016

Figure 6: Contribution of integration to Implant coverage (Source: HIS HPO Karusi.)

2,500 2295 • In 2015, there were 2.5 times more implant users in demonstration sites (1,558) than in 2,000 other sites (619) 1,558 1,500 • In 2016, new implant users were 2.3 times

985 more numerous in demonstration sites 1,000 619 (2,295) than in other sites (985) 500

0 Pilot Sites Non-pilot Sites

Implants 2015 Implants 2016

Figure 7: Contribution of QI/ Integration to coverage of long-acting methods in Karusi Health Province. (Source: HIS HPO Karusi).

5000 4,435 • Out of the 570 IUDs implanted across the 4500 province, the 11 pilot sites contributed 66 %, 4000 3500 representing 376 IUD users. 3000 • On the other hand, out of 4,435 new 2500 2,295 2000 implant users across the province, pilot 1500 sites contributed 2,295 implants (51.7 1000 570 376 %). These improvements have resulted in 500 0 Karusi Health Province ranking from 16th Pilot Sites Total Province to 4th among Burundi's 18 provinces in 2016 IUD Acceptors 2016 Implants Acceptors contraceptive coverage.

Integration of Essential Health Services in Burundi through the Use of 17 the Collaborative Quality Improvement Model 17 Improved integration of early ANC, SGBV care and HIV testing in curative services in Kirundo health province 1. Project rationale and expected benefits A significant number of pregnant women, children under 5 and other patients use health services for curative consultations, especially at the health center level and more than 65% of consultations are malaria cases. In 2014, statistics showed that the rate of HIV prevalence and the existence of gender-based violence cases were high, and the rate of early prenatal consultation (ANC) was low (13.8%). Integrating these services into curative consultations should reduce missed opportunities to provide these services.

2. Project goal Increase the rate of early ANCs as well as HIV testing and sexual and gender-based violence care, through integrating these services into curative consultation.

Table 7: Improvement objectives and monitoring Indicators

Objectives Indicateurs Improve the provision of early ANC services to Proportion of pregnant women seen in pregnant women seen in curative consultation. curative consultation who received early ANC.

Improve the provision of prevention and care services Proportion of SGBV victims who received for sexual and gender-based violence. PEP.

Improve provider-initiated HIV testing and counseling Proportion of patients counseled and tested for all cases seen in curative consultation. for HIV in curative consultation.

3. Results Objective: Improve the provision of early ANC services to pregnant women seen in curative consultation.

18 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model

Theé decisionioration for the ’ iintegrationntégratio projectn awas guided ré byo a low contraceptiveri n ar coverageg rate of 24%, while éthei nationaltag average an was 30.8%,ri and ther afactti that 89%a rofo childrenin areceivednitair the BCGir vaccine,no which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal and child health (MCH) services therefore offers an opportunity to increase access to and use of contraception tiiat.i on rot t énéi attn n nor iortant nint d’enfants de moins de 5 ans et autres atint tiint ri anté or ontation rati notant a nia ntr anté t 2. Goal and objectives Increase the contraceptive a onrnnt coverage ai rate through integrating tatiti FP réntservices intoontrnt immunization taand post - prévalencenatal consultation en VIH, (PNC)l’existence services des. cas de violence basé r gnr ont éé t ta ontation rénata réo t a L’intégration de ces services dan ontation ratiTable 6 :rait Improv emrttrent obj ect iréirves and mo oortniténitoring indica manquéestors d’orir ri

Objectives Indicators t rot Reduce missed opportunities to offer FP % of women who bring children for gntr ta réo aini éitag ion t aé counseling to any woman who brings her child to immunization services and who received FP sur le genre, par l’intégration de ces services dans la consultation rati the immunization service/unit and any woman counseling.

seen in post-natal consultation (PNC). % of women seen in PNC and who received FP aa Objectifs d’amélioration et Indicateurs de suivi counseling. ti niatr Reduce missed opportunities to provide FP % of women who bring children in for Améliorer l’offre des services de CPN réo a roortion nint n methods to women who bring their children in for immunization services who received FP nint n ontation rati ontation rati i ont énéiié a immunization services and women seen in PNC. methods réo Améliorer l’offre des services de prévention t %roortion of women seen iti in PNC who aantreceived r FP ri n arg éia ion methoda s. aéReduce r missed gnr opportunities to provide FP % of hospitalized women who received FP éiorrservices to womenoni admittedt éitag to (hospitalized in) counseling.roortion atint onié t éité maternity wards and those who have given birth, % of women who gave birth in maternity wards l’initiative du prestataire pour tout a n or n ontation rati ontationparticularly rati through caesarean deliveries. and who received FP methods. The decisionIncrease forthe the demand integration for projectFP methods was guided at theby a low% of contraceptive women referred coverage by CHWs rate ofto 24%, HCs whilefor FP community level. counseling and who received a FP method. the national é averagetat was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal 3. Results and childti Ahealthmélio r(MCH)er l’off rservicese des se rthereforevices de C PoffersN préc anoce opportunity aux femmes toen cincreaseeintes vu accesses en oton andta tiuseon of contraceptionrati . Objective: Reduce missed opportunities to offer family planning counseling (FPC) to any woman who rapieFigure 8: Percentage Porcentage of pregnant de emmes women enceintes seen in curative es en consultation consltation in pilot cratie and extension des sites sites pilotes et d’etensionbwho2ri.n g Gsreceived hoealr i acnhdi lont dearlyo bto jénéiciée tc hANCteiv iems in m Kirundoudeni zlaa tCPNio nhealth s précoceervi cprovince.e/u ndansit. la proince sanitaire de irndo Increase the contraceptive coverage rate through integrating FP services into immunization and post- Figure 1: Percentage of women who bring children in for immunization services who were given FP natal consultation (PNC) services. counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. Table 6: Improvement objectives and monitoring indicators 100 Objectives Indicators

80 L.S.2 Reduce missed opportunities to offer FP % of women who bring children for

60 L.S.1

counseling to anys woman who brings her child to immunization servicesExtension and who received FP 40 e g Changes

the immunization20 n service/unit and any woman counseling.

a seen in0 post-natalh consultation (PNC). % of women seen in PNC and who received FP C counseling. Reduce missed opportunities to provide FP % of women who bring children in for PilSitesot si tpiloteses ExteSitesnsio nd'extension sites methods to women who bring their children in for immunization services who received FP 2015 2016 2017 immunization services and women seen in PNC. methods rFrom n Juneério 2015 to Dec.2017, oi n tt156,021 gro women broughta été té their children an in ri for vaccinat ratiion, of itwhom Over a period of 30 months, a pregnancy test was% of carried women out seen in curativein PNC serviceswho received of FP pilotes143,172 et d’(92%)tnion received FP tot counseling . Thisi rate n hasg rapidly rorér increased a since rtar the initiation ntration of the changes, pilot and extension sites for every woman girl ofmethod childbearings. age with more than 10 days orfrom ari 73% to 89% and maintained ont at tt 100% ’t throughout rééé oiti the extension oit phase aaint. n gro oinReduceof menstruation missed opportunities delay.i ont Among bénéficié to 11,402provide d’une women CPN FP réo %whose of hospitalized test were rir positive, women tritr 9,185who orreceived 81% FP or aserviceshad n a at topregnancy women ri admittedof less than to (hospitalized12 WAs. oni These in) t ttwomencounseling. benefited from an early, same day maternity ANC (first wards trimester and those ANC1) who have with given a package birth, of% services of women (LLIN, who gave IPT, birth and in HIVmaternity counseling wards particularly through caesarean deliveries. and who received FP methods. and testing). Increase the demand for FP methods at the20 15 % of women referred by CHWs to HCs for FP community level. counseling and who received a FP method. LesThe efforts QI/Integration d’AIntégration efforts ont contricontributedbué accroitreto the increase le taux dein theCPN early précoce ANC qui rate était from de 14% avant l’approce et a atteint un pic de pour une moenne mensuelle de La mme dnamique de before3. Re stheults approach to a peak of 98% for a monthly average of 79%. The same progressive progressiondynamic iss’ observeobserved dans in theles sites extension dextension sites. Ob jective: Reduce missed opportunities to offer family planning counseling (FPC) to any woman who apie Comparaison des cas de CPN précoces enregistrées dans les sites d’Intégration et les brinFiguregs her 9:ch Comparisonild to the im mofu earlynizat iANCon s ecasesrvice /recordedunit. in Integration sites and other sites from January atesto December sites de an2016ie in Kirundo ee Province. dans la Poine de indo. Figure1000 1: Percentage of women who bring children in for immunization services who were given FP counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. 800

100600 80 400 60 s

40200 e g

20 n a

0 0 h C A A O N

PiloSitest sit piloteses ExtenSitession non site pilotess

2015 2016 2017 FromData June analysis 2015 to of Dec.2017,the above 156,021chart shows women that brought the number their ofchildren pregnant in for women vaccinat whoion, receive of whom L’analseearly ANC des donné is twicees montreas high que in the le nombre integration des femmes sites as enceintes in the other qui bénéficientsites. d’une CPN précoce 143,172est deux (92%) fois receivedplus élevée FP counselingdans les sites. This d’intégration rate has rapidly que dansincreased les autres since sitesthe initiation of the changes, from 73% to 89% and maintained at 100% throughout the extension phase. ObIntegrationjectif : Amé lofior eEssentialr l’offre d eHealths servic Serviceses de pré vine nBurundition et d throughe prise en the ca Userge ofmé dicale des violences 19 sethexue lCollaborativeles basées sur le Quality genre Improvement Model apie Poentae de ities de aant e la PP dans les sites pilotes et d’extension. 15

A A Extension A O N A A O N A A O N Avant lIA 5 Sites pilotes Sites d'extension

Avant l’introduction de l’approche AQIntégration, peu ou pas de cas de V étaient notifiés dans les formation Les A ont initié des cangements notamment la sensibilisation de l’administration locale élus locaux, confessions religieuses, AC et autres acteurs sur l’importance de la référence immédiate des victimes de V ur une période de deux ans et demi, cas des victimes de V ont été enregistrés en consultation curative des sites pilotes et d’extension Parmi elles, ont reu une proplaxie post exposition dans les eures dans la mme structure et le mme jour avec une moenne mensuelle de

Ce taux a connu une bonne performance qui a évolué progressivement dans les sites pilotes, passant de 0% avant l’intégration 5 en uillet pour se stabiliser

The decision for the integration project was guided by a low contraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal and child health (MCH) services therefore offers an opportunity to increase access to and use of contraception.

2. Goal and objectives Increase the contraceptive coverage rate through integrating FP services into immunization and post- natal consultation (PNC) services.

Les efforts d’AIntégration ont contribué accroitre le taux de CPN précoce qui était de avant Table 6: Improvement objectives and monitoring indicators l’approce et a atteint un pic de pour une moenne mensuelle de La mme dnamique de Objectives Indicators progression s’observe dans les sites dextension Reduce missed opportunities to offer FP % of women who bring children for counseling to any Comparaison woman who desbrings cas her de childCPN précocesto immunization enregistrées services dans lesand sites who d’Intégration received FP et les the immunization service/unit and any woman counseling . seen in post-natal consultation (PNC). % of women seen in PNC and who received FP 1000 counseling. Reduce800 missed opportunities to provide FP % of women who bring children in for methods to women who bring their children in for immunization services who received FP 600 immunization services and women seen in PNC. methods 400 % of women seen in PNC who received FP 200 methods. Reduce missed opportunities to provide FP % of hospitalized women who received FP services0 to women admitted to (hospitalized in) counseling. maternity wards and those who haveA given birth, % of women whoA gave birth inO maternityN wards particularly through caesarean deliveries.Sites pilotes and Siteswho nonreceived pilotes FP methods. Increase the demand for FP methods at the % of women referred by CHWs to HCs for FP community level. counseling and who received a FP method. L’analse des données montre que le nombre des femmes enceintes qui bénéficient d’une CPN précoce est3. deuxRes ufoislts plus élevée dans les sites d’intégration que dans les autres sites Objective: Improve the provision of prevention and care services for sexual and Objectif : Améliorer l’offre des services de prévention et de prise en carge médicale des violences Objegender-basedctive: Reduce violencemissed opportunities to offer family planning counseling (FPC) to any woman who brinsegsx uheelrle csh bilads téoe sth seu rim lem guenirzeat ion service/unit. ’ Figure 10: Percentage of SGBV victims who received PEP in the pilot and extension sites. Figure 1: Percentage of women who bring children in for immunization services who were given FP

counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. 100 80 L.S.1 60 L.S.2 s

40 e Extension

g 20 n a A O N A A O N A A O N 0 h C Avant lIA 5 PiloSitest site pilotess ExtensiSiteson si td'extensiones 2015 2016 2017 FromBefore June the2015 introduction to Dec.2017, of 156,021the QI/Integration women brought approach, their childrenlittle to noin forSGBV vaccinat casesion, were of whom 143,172Avantreported (92%) l’introductio in received the healthn deFP l’approchecounseling facilities. .AQ TheThisIntégration rateQITs has have rapidly, peu initiated ouincreased pas changesde sincecas de includingthe V initiation étaient sensitizing of notifi the changes,és dans les fromformationlocal 73% administration, to 89% Les andA maintained ont localinitié deselected at cangements100% officials, throughout notamment religious the extension denominations,la sensibilisation phase. deCHWs l’administration and other locale élusactors locaux, on the confessions importance religieuses, of immediate AC et referral autres acteurs of SGBV sur victims. l’importance Over de a laperiod référence of two immédiate des victimes de V ur une période de deux ans et demi, cas des victimes de V ont été and a half years, 284 cases of SGBV victims were recorded in curative consultation of pilot enregistrés en consultation curative des sites pilotes et d’extension Parmi elles, ont reu and extension sites. Of these, 266 (94%) received post-exposure prophylaxis within 72 une proplaxie post exposition dans les eures15 dans la mme structure et le mme jour avec une hours in the same health facility and the same day, with a monthly average of 87%. moenne mensuelle de

CThise taux rate a connu has performed une bonne performancewell and has quiprogressively a évolué progressivement evolved in pilot dans sites, les from sites 0%pilotes before, passant deintegration 0% avant l’tointégration 50% in July 5 2017, en uilletand eventually pour stabilized se stabiliser at 100%.

Objective: Improve provider-initiated HIV testing and counseling (PITC) for any case seen in curative consultation. Since the start of the integration in 2014, HIV21 testing in curative consultation was oriented to PITC: any patient not knowing his/her serological status was counseled and tested if he/she accepted. In this context, during a period of 18 months (June 2015 to December 2016), out of a total of 34,170 patients received in curative consultation, 13,319, (39%) were counseled and tested for HIV, compared with 17% before the approach. However, as the positivity rate was low (1.1%), this strategy was oriented to targeted testing (patients with risk factor) since the start of the extension phase; this contributed to the detection of 104,602 patients, of which 2,142 (2%) were positive, with a variation of 0 to 6% according to HFs.

20 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Improved integration of FP into MCH and HIV care services in Kayanza health province 1. Project rationale and expected benefits Since the presidential standard for free maternal health care in 2006, a large number of pregnant women have been using health services for pre- and post-natal consultations, both at health centers and district hospitals. According to the 2013 PNSR activity report, 88% of pregnant women are seen at least once in ANC, 49% of women give birth in health care settings and 80% of them receive PNC services. However, FP contraceptive coverage in Kayanza province remains low at 25.7%, compared to a national average of 30.8%. Ad- ditionally, according to data available in 2013, FP coverage among HIV-positive women is very low, with a rate of 9% at Kayanza Hospital. Integrating FP into maternal health services (ANC, deliveries, PNC) and PLHIV care services is, in principle, an opportunity to increase access to contraceptive methods.

2. Project goal/objectives Increase the contraceptive coverage rate in maternal health and PLHIV care services.

Table 8: Improvement objectives and monitoring indicators

Improvement objectives Indicators (targets) Reduce missed opportunities to offer FPC to Percentage of pregnant women who received pregnant women and/or couples seen in ANC. FP counseling in ANC.

Reduce missed opportunities to offer FP methods Percentage of women seen in PNC while to women seen in PNC. pregnant who received FP methods.

Reduce missed opportunities to offer FP methods Percentage of HIV-positive women coming in to women monitored in HIV care services/units. for HIV services who received FP methods.

3. Results Objective: Reduce missed opportunities to offer FPC to pregnant women and/or couples seen in ANC.

From October 2015 to December 2017, out of a total of 77,284 pregnant women who received ANC, 75,796 (98%) were counseled in FP. It should be noted that the proportion of pregnant women who received ANC FP counseling was not documented prior to integration.

Integration of Essential Health Services in Burundi through the Use of 21 the Collaborative Quality Improvement Model

The decision for the integration project was guided by a low contraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indication of a high rate of service use by mothers. Integrating FP into immunization and maternal and child health (MCH) services therefore offers an opportunity to increase access to and use of contraception.

2. Goal and objectives Increase the contraceptive coverage rate through integrating FP services into immunization and post- natal consultation (PNC) services.

Changes TFigureable 6 : 1:Im Ppercroventageement oofbj ewomenctives a nwhod m obringnitor ichildrenng indica into rfors immunization services who were given FP Objectives Changes Indicators counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. Reduce missed opportunities to offer FP % of women who bring children for counseling100 to any woman who brings her child to immunization services and who received FP the80 immunization service/unit and any woman counseling. seen60 in post-natal consultation (PNC). % of women seen in PNC and who received FP s e 40 L.S.2 counseling. g L.S.1 20 n Extension Reduce misseda opportunities to provide FP % of women who bring children in for L.S.2

h 0 C methods to women who bring their L.S.1 childrenA in forA Extension A A immunization services who received FP immunization services and women seenA in PNC . A method s A A PilotSites sites pilotes E%x teofn sSiteswomenion s d'extensionites seen in PNC who received FP 2015 Sites pilotes2016 methodSitess. d'extension 2017 FromeThe tau rateJune de ofnouvelles2015 new to acceptors Dec.2017, accetante of 156,021sFP de methodsméthodes women seen de brought in vuesPNC their enrose Co children from a est0% in assé tofor 36% vaccinat de in pilot ion, sites,of dans whom les Reduce missed opportunities to provide FP % of hospitalized women who received FP siteswith ilotesan average avec unrate tau of 21%,moen and de from et0% de to 26% in extension our les sites sites, d’ etensionwith a monthly avec une moenne e143,172services tau de (92%)to nouvelles women received accetanteadmitted FP counseling tos de(hospitalized méthodes. This rate hasdein) rapidlycounseling. vues increaseden Co asince est asséthe initiation de of the changes,dans les mensuelleaverage of de 23%. Aggregate es donné esdata agrégées from all de sitestous lesrevealed sites révlent that, out qu of’au 39,402 total sur women seen femmes in vues sitesfrommaternity ilotes 73% towards avec 89% un andand tau thosemaintained moen who de have at 100% given et throughout de birth, % theof our women extension les whosites phase gaved’etension. birth in avecmaternity une moenne wards en Co ont été mises sous méthode contracetive mensuelleparticularlyPNC, 8,729 de through (22%) es beganca donnéesarean usinges agrégéesdeliveries. a contraceptive de tous les method. sitesand révlentwho received qu’au FP total methods sur . femmes vues enIncrease Co the demand ont for été FP mises methods sous m atéthode the contracetive% of women referred by CHWs to HCs for FP bectif Réduire les occasions manquées d’offrir les méthodes de au femmes séroositives suivies communityObjective: Reduce level. missed opportunities to providecounseling FP methods and to who HIV-positive received a women FP method . dans les services de C monitoredbectif Ré dinui rHIVe les careocca sservices/units.ions manquées d’offrir le15s m éthodes de au femmes séroositives suivies rapie Proportion des emmes I posities mises sos métodes P dans les sites pilotes et d an3s .l esR seesruvlitcse s de C d’extension d’Octore écemre dans la proince de aana rapieFigure 12: Proportion Proportion of HIV-positive des emmes women I usingposities FP methodsmises sos in pilot métodes and extension P dans sites les sitesfrom pilotes et

Od’extensionOctoberbjective: 2015Re d’Odu tocctoree December miss ed op 2017po écemrertu inn iKayanzaties t o o fprovince.fe rdans fam ilaly pproincelanning cdeou aananseling (F PC) to any woman who brings her child to the immunization service/unit.

Changes Figure 1: Percentage of women who bring children in for immunization services who were given FP

Changes counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. 100 80 Extension 60 s

40 e g S O N D J F M A M J J A S O N D J F ExtensionM A M J J A S O N D 20 n a

0 h 2015S O N D J F M A M J2016J A S O N D J F M A M J2017J A S O N D C Sites pilotes Sites d'extension 2015 2016 2017 ans un délai de deu ans et moisPilo t sSitesit efemmess pilotes séroositivesExtensioSitesn sit ed'extensionens ge de rocréer ont été mises sous méthode de armi une cohorte de suivies soit dans les services de C du ans les ans un délai de 2015deu ans et mois femmes2016 séroositives en ge de rocréer2017 ont été mises sous sites d’etension ce tau est de sur dans un délai de mois Fromméthode22 June de 2015 armi to Dec.2017, une cohorte 156,021 deIntegration women suivies ofbrought soit Essential their dans Health children les Servicesservices in for de invaccinat BurundiC duion, through of ans whom les

143,172sites d’etension (92%) received ce tau FP est counseling de . Thisthe rateUsesur ofhas the rapidly dans Collaborative un increased délai de since Quality mois the initiation Improvement of the Model changes, Contribution de l’intégration l’augmentation de la couverture contracetive de la rovince de aana from 73% to 89% and maintained at 100% throughout the extension phase. la fin de la hase de démonstration Contribution de l’intégration l’augmentation de la couverture contracetive de la rovince de aana Avant d’étendre les améliorations obtenues dans le reste des formations sanitaires les effets de la fin de la hase de démonstration l’intégration ont été mesurés en comarant les résultats obtenus dans les sites d’A avec autres Avant d’étendre les améliorations obtenues dans le reste des formations sanitaires les effets de sites qui n’ont as eérimenté l’aroche l’intégration ont été mesurés en comarant les résultats15 obtenus dans les sites d’A avec autres

sites qui n’ont as eérimenté l’aroche

Within 2 years and 4 months, 210 (71%) HIV-positive women of childbearing age began using FP-methods among a cohort of 296 followed up in HIV care. Within a 10 month- period, this rate is 40% (117 out of 295) in extension sites.

Contribution of integration to increased contraceptive coverage in Kayanza Province at the end of the demonstration phase.

Before extending achieved improvements to the rest of the health facilities, the effects of integration were measured by comparing results obtained in 15 QI sites with 15 other sites that did not pilot the approach.

Figure 13: Comparison of acceptors of three methods (IUDs, implants and DMPA) in 15 QI sites and 15 control sites (Source: HIS HPO Kayanza).

35000 31503 30000 25000 20000 16756 15000 10000 5000 141 93 1192 855 0 IUD Implants DMPA

QI Sites Non QI Sites

Figure 13 shows that QI sites have respectively 1.5 and 1.4 times newer IUD and implant users than sitesFigure that 13did shows not pilot that the QI approach sites have. respectively 1.5 and 1.4 times newer IUD and implant Furthermore, QI sites have almost twice as many new DMPA users than sites that have not piloted the users than sites that did not pilot the approach. Furthermore, QI sites have almost twice as approach. many new DMPA users than sites that have not piloted the approach. Improving the Integration of Malaria Prevention Services in Muyinga Health Province

1. Project rationale and expected benefits : Malaria is the leading cause for curative consultations among pregnant women and children under age 5, and the major cause of infant morbidity and mortality. Additionally, ANC coverage shows satisfactory results with a rate nearly 100%, while the rate of assisted delivery in a health care setting is 84.7%. The integration of malaria prevention services into ANC services is therefore an opportunity to help reduce the rate of morbidity and mortality among pregnant women.

2. Project goal: Integration of Essential Health Services in Burundi through the Use of 23 Increase the level of integration of malaria prevention into CPN services. the Collaborative Quality Improvement Model

Table 9: Improvement objectives Improvement objectives Indicators Improve the package of malaria prevention services % of pregnant women seen in ANC1 who for pregnant women seen in ANC received long-lasting insecticide-treated nets (LLINs) % of pregnant women seen in second trimester of ANC who received IPT2

3. Results

Objective: Improve the package of malaria prevention services in ANC a) Improve the provision of LLINs for women attending ANC1

Figure 15: Percentage of pregnant women attending ANC1 who received LLINs in the pilot and extension sites from November 2015 to December 2017 in Muyinga province.

The decision for the integration project was guided by a low contraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is an indicationImproving of a highthe rateintegration of service use of by Malaria mothers. prevention Integrating FP intoservices immunization in Muyinga and maternal andhealth child health province (MCH) services therefore offers an opportunity to increase access to and use of contraception. 1. Project rationale and expected benefits Malaria2. Goa lis a nthed o bleadingjectives cause for curative consultations among pregnant women and Increase the contraceptive coverage rate through integrating FP services into immunization and post- children under age 5, and the major cause of infant morbidity and mortality. Additionally, natal consultation (PNC) services. ANC coverage shows satisfactory results with a rate nearly 100%, while the rate of assisted Tabldeliverye 6: Impr inov eam healthent ob jcareectiv settinges and m iso 84.7%.nitoring Theindic aintegrationtors of malaria prevention services Obintojecti vANCes services is therefore an opportunity Itond helpicato rreduces the rate of morbidity and Reducemortality missed among opportunities pregnant women. to offer FP % of women who bring children for counseling to any woman who brings her child to immunization services and who received FP the2. immunizationProject goal service/unit and any woman counseling. seen in post-natal consultation (PNC). % of women seen in PNC and who received FP Increase the level of integration of malaria preventioncounseling into. CPN services. ReduceTable 9:missed Improvement opportunities objectives to provide FP % of women who bring children in for methods to women who bring their children in for immunization services who received FP immunizationImprovement services objectives and women seen in PNC. Indicatorsmethods Improve the package of malaria prevention % %of pregnantof women women seen seen in PNCin ANC1 who who received received FP services for pregnant women seen in ANC long-lastingmethods. insecticide-treated nets (LLINs) Reduce missed opportunities to provide FP % %of pregnantof hospitalized women seenwomen in second who trimesterreceived ofFP ANC who received IPT2 services to women admitted to (hospitalized in) counseling. maternity wards and those who have given birth, % of women who gave birth in maternity wards

particularly through caesarean deliveries. and who received FP methods. 3. Results Increase the demand for FP methods at the % of women referred by CHWs to HCs for FP communityObjective:bectif A mlevel Improveélio. rer le theaq packageuet des s eofr vmalariaices de preventionrévencounselingtion d uservices al uanddis minwhoe ANCe nreceived C a FP method. aa. ImproveAméliorer the l’offre provision du MIILDA of LLINs our forles femmeswomen attendingvues en C ANC1 3. Results ieFigure 15: Percentage oente of pregnant des ees women eattendingneintes esANC1 en who received nt LLINs e inne the pilot and dns es sites Obpilotesjeextensionctive :et R ed’extension dsitesuce mfromisse Novemberded o Nppoeeortun 2015itie s toto Decembero ff eeer fami l2017y pl a ninn iMuyingan gdns cou n sprovince. eoineling (FPC de) to in any wom an who brings her child to the immunization service/unit. Stock out Figure 1: Percentage of women who bring children in for immunization services who were given FP counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. 100 80 60 Changes Extension s

40 e g

20 n a

0 h AvAC

PiloSitest sit epilotess ExtenSitession d'extension sites

2015 2016 2017 FromBien June avant 2015 l’approche to Dec.2017, d’A les 156,021 A womenétaient donnébroughts au their femmes children enceintes in for vuesvaccinat en Cion, ofde whommanire 143,172inconsista (92%)nte received Depuis FP l’ introductioncounseling. This des rate changement has rapidlys increaseddans le cadre since thede initiationl’A le ofourcentage the changes, des fromfemmes24 73% to enceintes 89% and vues maintained en C at aant 100%Integration bénéficié throughout ofdes Essential the extensionA a Health augmenté phase Services. de in Burundi en through ovembre our se stabiliser ensuitethe es Use rutures of the deCollaborative stoc de A Quality au ni Improvementveau central survenues Model durant la ériode entre etembre et évrier eliquent la baisse rovisoire de ce tau ans les sites d’etension ceendant on note une erformance constante de 15 b Améliorer l’offre du che les femmes enceintes vues en C e LS recommande qu’une femme enceinte doit recevoir au moins deu doses de endant la grossesse

ie oente des ees eneintes es en nt ees e dns es sites pilotes et d’extension de oee ee dns oine de in

L.S.2 S O N D J F M A M J J A S O N D J F M A M J J A S O N D Changes 2015 2016 2017 Axis Title

Sites pilotes Sites d'extension

e grahique montre une rogression constante du tau de femmes enceintes recevant deu doses de en C de % puis 24 % avant l’A ne tendance nette vers l’amélioration s’observe ars des changements dans les sites ilotes assant de en anvier en ovembre ars la deuime A durant laquelle les changements ont été adatés Ce tau a continué augmenter

bectif Améliorer le aquet des services de révention du aludisme en C Thea decisionAméliorer for thel’offre integration du MIILDA project our leswas femmes guided byvues a low en Ccontraceptive coverage rate of 24%, while the national average was 30.8%, and the fact that 89% of children received the BCG vaccine, which is anie indication of a oentehigh rate of servicedes ees use by eneintes mothers. es Integrating en FP nt into eimmunization ne and dns maternal es sites andpilotes child et health d’extension (MCH) de services Noee therefore offersee an opportunity dns to oine increase de access in to and use of contraception. Stock out 2. Goal and objectives Increase the contraceptive coverage rate through integrating FP services into immunization and post- natal consultation (PNC) services. Table 6: Improvement objectives and monitoring indicators Objectives Changes Indicators Extension Reduce missed opportunities to offer FP % of women who bring children for counseling to any woman who brings her child to immunization services and who received FP the immunizationAvA service/unit and any woman counseling. seen in post-natal consultation (PNC). % of women seen in PNC and who received FP Sites pilotes counselingSites d'extension.

Reduce Before missed the QI approach,opportunities LLINs to wereprovide inconsistently FP % of womenprovided who to bring pregnant children women in for methodsBienattending avant to l’women approcheANC1. who Since d’ Abring introducing les their A children étaient changes in fordonné withinimmunizations au the femmes QI process, services enceintes whothe vues percentage rec eneived C FP ofde manire immunizationinconsistapregnantnte women services Depuis attending andl’introduction women ANC1 seen d es whoin PNCchangement received. method LLINss danss has le cadreincreased de l’fromA le 30% ourcentage to 77% in des femmesNovember enceintes 2015 vuesand enstabilized C aant at 100% bénéficié thereafter. des% of AStockwomen a augmentéouts seen of LLINsin de PNC at whothe centralreceived en levelovembre FP our se stabiliser ensuite es rutures de stoc de A au niveau central survenues from September 2016 to February 2017 explainmethod the temporarys. decline in this rate. In the Reducedurant lamissed ériode opportunitiesentre etembre to provide et évrier FP % of eliquent hospitalized la baisse women rovisoire who receivedde ce tau FP ans extension sites however, there is consistent performance at 100%. servicesles sites tod’ etensionwomen admitted ceendant to (hospitalizedon note une erformancein) counseling. constante de maternity wards and those who have given birth, % of women who gave birth in maternity wards particularlybb. AméliorerImprove through the l’offre offer c aduesarean of IPT2 che deliveries. in lespregnant femmes womenenceintesand attending who vues received en CPN3.C FP methods. IncreaseeThe LS MSPLSthe recommande demand recommends for qu’une FP that methodsfemme a pregnant enceinte at the woman doit% ofrecevoir shouldwomen au receive referred moins atdeu byleast CHWs doses two todedoses HCs endantforof SP FP la communitygrossesseduring pregnancy. level. counseling and who received a FP method.

ieFigure3. Re 16:su l Percentagets oente of pregnant des ees women attendingeneintes ANC3es enwho received nt IPT2 ees in pilot e and extension dns es sites pilotessites fromet d’extension November de 2015 oee to December 2017 ee in Muyinga province. dns oine de in Ob jective: Reduce missed opportunities to offer family planning counseling (FPC) to any woman who brings her child to the immunization service/unit.

Figure 1: Percentage of women who bring children in for immunization services who were given FP counseling in pilot and extension sites from June 2015 to December 2017 in Karusi province. 100

80 L.S.2 60 s

40 e S O N D J F M A M J J A S O N D J F M A M J J A S O N D g Changes 20 n a 2015 2016 2017 0 h C Axis Title

PiloSitest sit epilotess ExtenSitession sd'extensionites 2015 2016 2017 e grahique montre une rogression constante du tau de femmes enceintes recevant deu doses FromdeFigure June en C162015 shows deto Dec.2017, a steady% puis increase 156,02124 % avant inwomen thel’A rate broughtne of tenda pregnant theirnce nettechildren women vers in receivingl’amélioration for vaccinat two ion, s’dosesobserve of ofwhom ars 143,172desIPT chan in(92%) gementsANC3 received from dans FP 0 les counselingto sites7%, andilote. Thisthens rateassant 24% has before rapidlyde QI. increased en A clearanvier since trend the towards initiation en improvement ofovembre the changes, fromarsis 73% observed la deuimeto 89% after and A maintainedintroducing durant laquelle at 100%changes les changementsthroughout in pilot sites,the ont extension fromété adatés 45% phase in C Januarye. tau a continué2016 to 68% augmenter in November 2017 after the second WA, during which the changes were adapted. This rate continued to increase, reaching 87% in December 2017. In the extension sites, this rate remained stable around 63%. 25 15

Integration of Essential Health Services in Burundi through the Use of 25 the Collaborative Quality Improvement Model Lessons learned from piloting activities of improving service integration On using the Collaborative Quality Improvement Model • The functionality of improvement teams -- Positive points: i) The teams, set up by coaches with technical support from the IHPB project, included a community representative; ii) The accessibility of work/ job aids for meeting management and binders, made available to archive meeting minutes, facilitated the work of QITs and is documentation of their functionality by the coaches; iii) Meetings were held regularly in most sites (on average two meetings per month) as reflected in their minutes. -- Problems encountered: i) The QIT chair chosen can positively or negatively affect the functionality and performance of a QIT; ii) At the beginning of the approach, poor performance at a Karusi site was due to the QIT Chair not being involved and not convening meetings; ii) There was distinct performance in this site when the chair was changed and replaced by a more dynamic chair; iii) Hospital teams are less motivated and dynamic, with an irregular meeting schedule, than health centers because of their staff’s multivariate profiles and skills. • The coaching system -- Positive points: i) Joint coaching (districts/IHPB) visits are essential activities in the QI process as it is through these visits that QITs begin to understand the approach, develop their initial process diagram, test ideas for changes and measure the effect of changes on monitoring indicators; ii) The hiring/establishment of QI Officers in the field has steadily revitalized the coaching system. -- Problems encountered: i) District supervisors trained on coaching techniques were often called on for other district management activities, which limited regular coaching visits; ii) District supervisors find it difficult to coach physicians because of their hierarchical relationships, which accentuated low motivation in hospital teams. • The monitoring system -- Positive points: The Excel database with embedded charts facilitated results analysis during learning sessions and preparation for presentations. -- Problems encountered: i) Data transmission and analysis before the production and submission of reports is another QI area where challenges,

26 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model such as misunderstanding denominators of some indicators and errors in the transcription of data from the register to the report form, still exist despite improvement efforts; ii) Given the large number of facilities involved, especially after extension, prompt reporting was not assured. • Testing changes -- Positive points: i) Developing a patient-specific integration process diagram has allowed teams to identify bottlenecks and propose solutions; ii) The QITs have identified existing problems, looked for their root causes and proposed local solutions. A work/job aid allowed the QITs to understand how to plan for change, introduce it and study/assess effects of change in terms of results. -- Problems encountered: i) Some QITs confused changes with activities (implementation of change); ii) In the "Act" step of the PDSA cycle, some teams did not always think to modify a less effective change. Usually after learning exchanges, teams altered their changes that were to be tested. • Learning sessions: -- Positive points: We observed improvement in performance after each learning session during which QITs exchanged their experiences and modified the ideas for changes being tested based on results from other QITs. -- Problems encountered: Scheduling conflicts limited the availability of local health authorities, delaying certain learning sessions. • Intra and inter-provincial extension: -- Positive points: i) Extension sites quickly adopted best practices, resulting in faster achievement of results than in pilot sites; ii) QITs of new extension sites expressed their satisfaction in being mentored by their colleagues/peers from pilot sites because, according to them, they could freely ask questions on aspects that were not understood during the learning sessions. -- Problems encountered: The inter-provincial extension included the integration of the extended collective package of services. At the midterm results exchange workshop, some sites indicated that there was a lack of qualified staff to improve all the indicators in this package. • Other factors that influenced improvement efforts: -- Frequent staff turnover, either in healthcare providers or DMOs, have influenced the dynamics of QITs and support from districts. New staff were not trained in the approach and took time to understand and get involved, which required additional awareness-raising by supervisors and coaches.

Integration of Essential Health Services in Burundi through the Use of 27 the Collaborative Quality Improvement Model On service integration

Successful integrations The results of Karusi and Kayanza show that the integration of FP services into MCH services (child immunization, PNC, maternity) and HIV patient care services is feasible by providers, accepted by clients and produced results.

According to QITs, early ANC integration into curative consultation services is feasible without difficulty and has become an established routine. Early ANC also increases the chances of completing third trimester ANC, an indicator supported by the Performance Based Financing (PBF) system, which is a source of motivation for providers. The premium granted by the PBF is used in part to cover the costs of free pregnancy tests.

The QITs noted that service integration has created a sense of satisfaction among clients who receive a service package on the same day, which saves time: • BCG vaccine for children, postnatal care for mothers, and family planning services; • Clients receive refocused ANC (HIV testing and counseling, IPT, LLINs and PMTCT) the same day instead of returning another day for the same services.

According to the Kigozi sister in-charge, discovering accidental pregnancies also has another advantage, which is to avoid prescribing a drug that is contraindicated during the first trimester.

Integration of HIV counseling and testing into curative consultation is feasible and, combined with targeted testing of at-risk patients, has raised the positivity rate.

The establishment of a LLIN requisition register and proper management of mosquito nets, has allowed adequate use of LLINs and the integration of malaria prevention services (LLINs and SP) into ANC.

The involvement of district medical officers (DMOs) is a key factor in the success of the collaborative approach. Their participation in the supervisions and their contributions to the learning sessions motivated/prompted the QITs to improve their work.

Limitations and constraints that may hinder the integration of services: The integration of services has its limits because it requires a different organization of care and a longer contact time between providers and patients.

28 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model The following change ideas were difficult to implement and/or did not achieve any results: • We observed that mothers received for curative consultation of their sick children are not receptive to FP counseling. Rather, they are concerned about the health status of their children; • Anthropometric measurements of pregnant women, breastfeeding women <6 months and children <6 months of age seen in curative consultation was abandoned, as malnourished cases went directly to the outpatient treatment service without going through the curative consultation services.

Sustainability of Results This improvement experience has demonstrated the feasibility and impact of integration on coverage and quality indicators of health services with substantial technical, logistical and financial support by the project. To sustain the results, the project, jointly with the districts, integrated the interprovincial change package into the district's annual action plans. In addition, HIS managers will integrate the monitoring system into their databases at the HDO level. Finally, the expanded collective package of changes will be integrated into the District Executive Teams’ supervision topics.

Integration of Essential Health Services in Burundi through the Use of 29 the Collaborative Quality Improvement Model Conclusion The smart integration opportunities identified by the health provinces and the districts have led to many changes that have contributed to the improvement of patient coverage in essential health services and the improvement of many performance indicators.

Skills acquired by QITs and their coaches allow them to integrate a continuous improvement dynamic into their daily practices to solve problems in organizing services and quality of care.

This unique experience demonstrates the versatility of the quality improvement model in its application to service integration goals. Lessons learned will allow the MOPHFA, provinces, districts and their partners to reproduce this experience in the rest of the country.

30 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Annexes Annex 1: List of HFs involved in the demonstration phase

Health Facilities (HFs) involved in the pilot phase of the Karusi Health Province.

BUHIGA District NYABIKERE District Masabo Health Center (HC) Rusamaza HC Nyaruhinda HC Nyabibuye HC Karusi HC Rusi HC Buhiga HC Gihogazi HC BUHIGA Hospital Nyabikere HC Gisimbawaga HC

Health Facilities (HFs) involved in the pilot phase of the Kirundo Health Province.

KIRUNDO District VUMBI District BUSONI District MUKENKE District Kirundo Hospital Rushubije HC Burara Mukenke Hospital Ruhehe HC Muramba HC Marembo HC Buhoro HC Kigozi HC Gikomero HC Kabanga HC Gitobe HC Kiyonza HC Ntega HC Bugorora HC Gakana HC Bucana HC

Health Facilities (HFs) involved in the pilot phase of the Kayanza Health Province.

KAYANZA District MUSEMA District GAHOMBO District Kayanza Hospital Musema Hospital Rukago HC Kayanza HC Matongo HC Ngoro HC Rubura HC Karehe HC Mubogora HC Kabuye HC Rango HC Gakenke HC Kavoga HC Nyarurama HC Gahombo Hospital

Health Facilities (HFs) involved in the pilot phase of the Muyinga Health Province.

MUYINGA District GITERANYI District GASHOHO District Muramba HC Kamaramagambo HC Gasorwe HC Rugabano HC Mugano HC Nyungu HC Murama HC Ruzo HC Nyagatovu HC

Integration of Essential Health Services in Burundi through the Use of 31 the Collaborative Quality Improvement Model Annex 2: Expanded collective package of changes and their implementation activities

Integration Improvement Tested changes Activities/Best practices Opportunities Objective Health Center Improve the Provide free pregnancy a) Make stock sheets available for and Hospital provision of early testing to any woman pregnancy test equipment (strips, levels ANC services or girl of childbearing urine vials, gloves) in curative to pregnant age who has come consultation. Curative and women seen for curative or b) Retrieve the pregnancy test gynecological in curative and gynecological obstetric equipment (urine test strips, urine – obstetric gynecological- consultation with containers, pedal bins, gloves) from service obstetric delayed menstruation the laboratory, and put it in the consultation. and who is not using a curative consultation room. contraceptive method. c) Collect the sample for the pregnancy test in the HC toilet. d) Perform the pregnancy test in the consultation room and deliver results through the same provider. Improve the a) Conduct a thorough a) Establish a SGBV listening and provision of medical history to look medical care service (for SGBV SGBV prevention for possible sexual victims). and medical care. violence, make a clinical b) Organize/facilitate a session on examination, record HE/week on SGBV at the HC. with a code (I/SGBV) in red for any case c) Make ARVs for post-exposure of SGBV, (change of prophylaxis, contraceptives and STI mood/behavior). treatment antibiotics available in the curative consultation service unit. b) Provide the complete care package for victims. Improve Providing counseling a) Indicate in red pen the I/PITC counseling and and targeted testing code for anyone who has accepted targeted HIV (patients with STI-, the test and accompany him/her to testing for any TB-malnutrition- risk the laboratory for sample collection. case seen in factors; female sex b) Provide the result on the curative and workers, opportunistic same day. gynecological- infections stigma) obstetric and index testing c) Provide care for anyone testing consultation. (family member of positive for HIV. PLHIV, multiple sexual partners) for anyone seen in curative and gynecological/ obstetrical consultations.

32 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Annex 2: Expanded collective package of changes and their implementation activities (continued)

Integration Improvement Tested changes Activities/Best practices Opportunities Objective Immunization Reduce missed Organize collective a) Set up a Health Education opportunities Health education notebook containing the topics to through sessions for women be developed integrating messages counseling any who bring children to on side effects and rumors. woman who immunization service, b) Organize the waiting room to brings her child facilitated by staff provide family planning counseling to immunization trained in FP. (FPC). service. c) Involve contraceptive method users to provide testimonies during collective/group Health Education sessions. d) Use audiovisual aids. e) Train unskilled personnel on FPC according to the availability of human resources. f) Refer mothers attending PNC and provide individual FPC.

PNC Reduce missed a) Provide individual a) Ensure appropriate leave planning opportunities FP counseling to any and limit staff authorization in order to provide FP woman who comes in to maintain continuity of FP service. services to any for PNC. b) Ensure the availability of short- woman attending b) Provide FP methods acting FP methods in the PNC PNC. daily to all women who service department. request them either c) Offer the method, if possible, in in the same service the same room and by the same department or refer provider to those who accept FP. them for FP service in the appropriate d) Accompany the clients to the FP department on the service unit for long-acting methods. same day. e) Hold a staff meeting to inform c) Receive, on a priority them that they must always give basis, women referred priority to clients referred by the by CHWs for FP community and accompany or refer methods. them to FP services. d) Invite men to f) Write invitation letter (ubutumire). accompany their wives g) Send the invitation letter to the in PNC to receive FPC partner, through the mother leaving together. the maternity ward. h) Organize PNC and BCG vaccination on the same day.

Integration of Essential Health Services in Burundi through the Use of 33 the Collaborative Quality Improvement Model Annex 2: Expanded collective package of changes and their implementation activities (continued)

Integration Improvement Tested changes Activities/Best practices Opportunities Objective Maternity Reduce missed a) Provide FP a) Assign staff qualified and trained opportunities counseling in the in contraceptive technology to the to provide FP maternity ward by staff maternity ward. services to qualified and trained b) Make FP methods (DMPA, COP) women who in FP. available by requisition at the have given birth hospital pharmacy. in the maternity b) Offer FP methods in ward, particularly the maternity ward to c) Record the methods on the those who those who accept. stock sheets. had caesarean d) Provide the FP method in the deliveries. same maternity ward by the same provider. HIV care Reduce missed a) Provide FP a) Develop a Health Education services opportunities counseling to any planning/calendar focused on FP. to provide FP HIV-positive woman of b) Develop key messages on services to all childbearing age who benefits, side effects and rumors HIV-positive are monitored in HIV about FP methods. women of care wards. childbearing c) Make a register available for the age, who are b) Provide all FP preparation of HE sessions. monitored in HIV methods in HIV care d) Stock FP inputs at the HC care services. services. pharmacy. e) Provide the FP method in HIV care services. f) Send out client cards to the FP service and file them in the service schedule after registration in the standard reception and FP registers. g) Train all HIV care providers locally in FPC. h) Assign to HIV care provision units qualified and trained staff in contraceptive technology. i) Match the date of appointment for ART supply with the date of checking or renewal of the FP method.

34 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Annex 2: Expanded collective package of changes and their implementation activities (continued)

Integration Improvement Tested changes Activities/Best practices Opportunities Objective ANC Improve the a) Provide the LLINs in a) Establish a requisition and daily package the ANC service ward consumption register of LLINs in the of malaria as part of refocused ANC ward/unit. prevention ANC. b) Establish a daily recording/ services in ANC. checking log to verify the LLINs • Improve the distributed in the ANC unit. LLIN provision c) Record each time LLINs were for women provided in the ANC register. attending d) Arrange appointments according ANC1/AR to the refocused ANC schedule: • 8 to 12 WA: 1st ANC • 18 to 24 WA: 2nd ANC • 8 to 32 WA: 3rd ANC • 36 to 38 WA: 4th ANC e) Inform the client of the appointment date and record it in her health booklet/card. Improve the b) Provide SP in the a) Set up a clean water point (water provision of ANC unit through filter) and cup in the ANC unit. IPT in pregnant trained personnel b) Update the internal requisition women attending under direct register for ANC inputs. ANC. observation. c) Record the requisitioned inputs on the SP daily inventory sheet. d) Give the pregnant woman the dose of SP on the spot. c) Supply the SP a) Correctly calculate the number of according to the pregnant women expected and order Average Monthly the SP based on the AMC. Consumption (AMC). b) Check the consumption of previous months on the stock sheets Improve a) Mark in the ANC a) Inform all ANC service providers recording register the number of that the ITP dose must be recorded of malaria times the SP dose is in the appropriate column of the prevention provided (1st SP, 2nd ANC Register. services provided SP….) b) Appoint a nurse to check at the to pregnant end of the day if all the data has women in the been entered in the ANC register. ANC register.

Integration of Essential Health Services in Burundi through the Use of 35 the Collaborative Quality Improvement Model Annex 2: Expanded collective package of changes and their implementation activities (continued)

Integration Improvement Tested changes Activities/Best practices Opportunities Objective ANC Improve b) Analyze the data a) Check, record and compile data. (continued) recording before transmitting b) Develop a schedule of review/ of malaria them analysis meetings. prevention services provided c) Invite QIT members to analyze the to pregnant data. women in the d) Transmit the corrected report ANC register. before the 25th day of the month (continued) following the month in question. e) Make a daily synthesis of the data from the ANC register. c) Record each time a) Compare the number of coupons the LLIN was provided distributed and the number of in the ANC register pregnant women seen in ANC1. b) Take a daily inventory of distributed LLINs. Reduce the a) Order LLINs on time, a) Develop a daily report of LLIN number of LLIN taking into account the distribution. and SP stock AMC b) Make a monthly inventory of the outs. LLINS. c) Keep the LLIN stock sheets up- to-date. d) Update the AMC every six months. e) Telephone or go to the HDO pharmacy to request information on the delivery date of LLINs to avoid a stock out. b) Order the SP in a a) Follow the calculation formula of timely manner, taking the AMC. into account the AMC. b) Follow the order form.

36 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Annex 2: Expanded collective package of changes and their implementation activities (continued)

Integration Improvement Tested changes Activities/Best practices Opportunities Objective Community Improve the Organize an a) Prepare topics on SGBVs to referral quality information/ develop.. of SGBV victims awareness meeting b) Send out an invitation letter. from the for local government/ community to local administration, c) Provide referral cards for SGBV. health centers. local elected d) Explain how to fill out the referral officials, religious sheets denominations, CHWs and other community e) Accompany the victim to HCs for stakeholders to explain care/support. the importance of f) File the community referral sheets immediate referral of at the HC. SGBV cases to the HC. g) Hold a monthly meeting to analyze CHWs’ referral sheets and activities. Increase the a) The CHWs provide a) Use work/job aids. demand for FP FPC to women who b) Make reference sheets/vouchers methods at the bring children in for available. community level. consultation within the framework of HMM. c) During meetings with CHWs held at the HC, compare the referral b) The CHWs provide vouchers provided with the number referral sheets/ of women who actually arrived at vouchers to women the HC. who accept, so that they can be received at d) Providers sponsor hills within the HC. their area of responsibility and participate in the FP awareness meetings organized by CHWs. Increase the rate a) Make/issue a) Develop key messages. of early ANC by announcements in b) Contact the administration and informing the various churches and religious leaders. population on mosques to raise the benefits of awareness on the c) Disseminate key messages. early ANC. benefits of early ANC. b) Conduct a joint a) Sponsor the hills of the HC’s area visit (nurse, health of responsibility. promotion technician, b) Identify key awareness messages CHW) to the hills (to be used) by CHWs. to sensitize the community on the c) Develop an awareness schedule. importance of early ANC.

Integration of Essential Health Services in Burundi through the Use of 37 the Collaborative Quality Improvement Model Annex 2: Expanded collective package of changes and their implementation activities (continued)

Integration Improvement Tested changes Activities/Best practices Opportunities Objective Community Increase the rate c) Send a reminder a) Identify women who have missed/ (continued) of early ANC by to pregnant women delayed ANC appointments. informing the with a delay in ANC b) Write invitation letters. population on attendance. the benefits of early ANC. (continued) Increase the Hold a monthly GASC a) Develop themes on the use of LLINs awareness meeting importance/benefits of using LLINs and IPT through on the importance/ and IPT in pregnant women. community benefits of using LLIN b) Convene a GASC meeting by awareness- and IPT in pregnant sending an invitation letter for the raising. women. meeting. c) Identify key messages for community awareness (to be used) by CHWs d) Develop an awareness schedule (to be used) by the CHWs.

38 Integration of Essential Health Services in Burundi through the Use of the Collaborative Quality Improvement Model Integration of Essential Health Services in Burundi through the Use of 39 the Collaborative Quality Improvement Model