QUALITY ASSURANCE PROJECT TECHNICAL REPORT SUMMARY The Niger QAP/BASICS Joint Project Center for Human Services • 7200 Wisconsin Avenue, Suite 600 • Bethesda, MD 20814-4811 • USA The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID), under Contract Number HRN-C-00-96-90013. QAP serves countries eligible for USAID assistance, USAID Missions and Bureaus, and other agencies and nongovernmental organizations that cooperate with USAID. The QAP team consists of prime contractor Center for Human Services (CHS), Joint Commission Resources, Inc. (JCI), Johns Hopkins University School of Hygiene and Public Health (JHSPH), Johns Hopkins Center for Communication Programs (JHU/CCP), and the Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO). It provides comprehensive, leading-edge technical expertise in the design, management, and implementation of quality assurance programs in developing countries. CHS, the nonprofit affiliate of University Research Co., LLC (URC), provides technical assistance and research for the design, management, improvement, and monitoring of healthcare systems and service delivery in over 30 countries. T E C H N I C A L R E P O R T S U M M A R Y The Niger QAP/BASICS Joint Project Abstract This summary presents the objectives, findings, lessons learned, and recommendations of the fall 1998 evaluation of a quality assurance (QA) program in Niger, a French-speaking Table of Contents country in West Africa with a population of 10 million. The I. Introduction ..................................................................................................... 1 Nigerien QA Project (QAP) began A. Events Influencing Nigerien Healthcare in the Late 1990s ....................... 1 in the Tahoua region in 1993 and in 1997 merged with another B. The Evaluation of the QAP/BASICS Project ............................................... 3 healthcare program—Basic C. Healthcare Environment Pre-QAP .............................................................. 4 Support for Institutionalizing II. TAP Objective Number 1 ................................................................................ 5 Child Survival (BASICS)—to A. Defining Quality .......................................................................................... 5 become the joint QAP/BASICS B. Immediate Results of the Supervisory System .......................................... 6 project. Later, the Konni District (Tahoua) and the Boboye District C. Improving Quality ........................................................................................ 7 (Dosso) were selected for QAP/ III. TAP Objective Number 2 ................................................................................ 9 IMCI (Integrated Management of A. Introducing IMCI in Niger ......................................................................... 10 Childhood Illness) interventions; B. Local Implementation ............................................................................... 10 this was the first time in the C. Results of Introducing IMCI in a QA Environment ................................... 10 history of international health interventions that IMCI was D. Dissemination of Information on the Nigerien QAP ................................. 12 introduced in an environment IV. Cost Analysis of the Niger QAP/BASICS Project ......................................... 12 where QA practices were in A. Sustainability Costs .................................................................................. 13 place. B. Basic QA and IMCI Training Costs .......................................................... 13 Important lessons learned from C. Training of Trainers ................................................................................... 13 the evaluation of the first five D. Team-Based Problem Solving .................................................................. 13 years of Nigerien QAP and QAP/ E. Supervision and Coaching ....................................................................... 14 BASICS relate to the savings and F. Supervision Checklist ............................................................................... 14 benefits derived from introducing IMCI in a QA environment, the G. Quality Meetings ....................................................................................... 14 ability of healthcare providers to V. Lessons Learned .......................................................................................... 14 learn and adapt QA principles A. For Niger ................................................................................................... 15 and implement solutions, the B. For the International Health Community .................................................. 16 development of teamwork among C. Main Factors Limiting QA ......................................................................... 16 QA-trained staff, and the importance of coaching and VI. Recommendations ........................................................................................ 17 meetings to support and sustain A. Establishment of Standards ..................................................................... 17 QA activities. The story of QA in B. Supervision and Monitoring of Standards ............................................... 17 Tahoua stands out as an C. Coaching and Quarterly Meetings ........................................................... 17 excellent example of how QA D. Problem Solving ........................................................................................ 17 activities can improve the quality of care, even in the face of E. Sustainability ............................................................................................. 17 severe resource constraints. F. Dissemination and Documentation .......................................................... 18 Acknowledgement The authors wish to express their appreciation to Youssef Tawfik, MD, MPH; Xavier Crespin, MD, MPH; and Mamoudou Djingarey, MD, MPH, for their participation on the evaluation team. The evaluation team is indebted to the staff of the QAP/BASICS project for their technical assistance throughout the mission and for the secretarial help, transportation, and equipment they made available. The team also appreciates the willingness of the departmental and district health authorities in the Tahoua and Dosso Departments of Niger to be available at all times. The evaluation team acknowledges the support provided by the USAID Mission in Niamey in funding this final evaluation and thanks the agency for providing the Quality Assurance Project with the opportunity to contribute to the success of the QAP/BASICS project in Tahoua and Dosso. The evaluation team’s work was supported through the Center for Human Services (USAID Contract No. HRN-C-00-96- 90013) and the BASICS Project (USAID Contract No. HRN 6006-C-00- 3031-00). Recommended citation Legros, S., E. Goodrich, and H. Abdallah. 2000. “The Niger QAP/ BASICS Joint Project.” Technical Report Summary 1(1). Published for the U.S. Agency for International Development (USAID) by the Quality Assurance Project (QAP): Bethesda, Maryland. About this series The Technical Report Summary series provides concise descriptions and background information on the Quality Assurance Project’s technical intervention results, evaluation results, and other project activities. This summary is derived from a longer report that was presented to Nigerien and U.S. officials immediately after the evalua- tion. For a copy of the longer report, write to [email protected] or call 301-941-8532. For more information on the evaluation of Niger’s QAP/BASICS project, please contact [email protected]. The Niger QAP/BASICS Joint Project Stephane Legros, Elizabeth Goodrich, and Hany Abdallah Missions, and field-based cooperat- ing agencies. The Center for Human Services (CHS) has operated QAP since its inception. I. Introduction During its first five years, QAP developed national and regional QA Based in Bethesda, MD, the Quality programs, stimulated QA interven- Assurance Project (QAP) helps tions in 16 countries, and conducted developing countries improve the training activities in another eight. Acronyms and Abbreviations quality of their healthcare services Since the start of its second five- by introducing quality assurance year phase in 1996, QAP has been ARI Acute respiratory infection (QA) tools and methods. Such tools placing greater emphasis on (e.g., checklists, flowcharts, cause- BASICS Basic Support for demonstrating the cost-effectiveness and-effect diagrams) and methods Institutionalizing Child Survival of QA interventions. Specifically, it is (e.g., standard setting, problem seeking to: (a) determine the cost- BPS Basic Package of (Healthcare) solving) ultimately enable a effectiveness of QA in national Services healthcare system to improve the programs, (b) document the impact health outcomes of the population CCM Combined Case Management and cost-effectiveness of QA served. QA has gained widespread through operations research, and CHS Center for Human Services acceptance in healthcare settings, (c) establish accreditation and other particularly as part of health sector IMCI Integrated Management of regulatory mechanisms. In 1993, reforms that seek to deliver cost- Childhood Illnesses QAP began to assist the Ministry of effective, equitable, and high-quality Public Health (MPH) in Niger in ISQua International Society