1. Leading Change From the Front Line In Afghanistan USAID Health Care Improvement (HCI) Project University Research Co., LLC Center for Human Services
Mirwais Rahimzai
MD, MBA, MPH (USA)
April 07, Amsterdam

2. Outline Brief Country Profile What and Where
URC Activities at 4 Levels:
Hospital Level
Health Facility Level (BPHS)
Community Level
National level
Keeping Quality Improvement Understood and Active at Different Levels

3. Brief Country Profile Population: About 25million
Maternal Mortality: 1,600/100,000 LB
Infant Mortality: 129/1,000 LB
Under 5 mortality: 191/1,000 LB
Fertility Rate: 6.3
CPR: 24% (Modern + Traditional)
BPHS: Coverage about 85% of the country
EPHS: Coverage about 60% of the country
Hemorrhage, Obstructed Labor, Sepsis, PIH
Asphyxia, Infection, LBW

4. HCI Goal in Afghanistan
533,518 out of 1,144,800 people in Balkh
477,677 out of 882,900 people in Kunduz
To improve quality and outcomes of health care by adapting and applying modern methods of quality improvement (QI)
Coverage in Herat
Coverage in Parwan
Coverage in Bamyan
Seven Hospitals in Kabul. Estimated catchment is 3,449,800 out of approximately 4,000,000

5. Intervention Package - Maternal Newborn Care Collaborative- Afghanistan
Service level
Phase One
Phase Two
ANC:
Birth preparedness/
complication readiness; Tetanus; Iron/Folate
ANC:
Screening, stabilization and referral for complications (prep-eclampsia and other)
Community
Post-partum: Screening, stabilization, and referralof maternal and newborn complications (sepsis, etc.)
Post-partum: Essential Maternal and Newborn Care; Danger sign recognition and care seeking
ANC:
Screening and management of
pre-eclampsia/eclampsia
Birth/Post-partum: Partogram; IP ;
complications management (hemorrhage, eclampsia, sepsis, newborn asphyxia and LBW), FP (LAM; progestin-based oral contraceptives)
BPHS
ANC:
Birth preparedness; Danger sign recognition, Tetanus
Birth/Post-partum: AMTSL/ENC; IP; maternal/newborn monitoring and discharge
Hospitals
Improve Prevention and early detection of PPH
Improve prevention and management of Birth Asphyxia
Improve maternal/newborn postnatal care
Improve Medical records
Maternal/neonatal sepsis
Eclampsia/ preclampsia
Triage
Obstrcuted labor
…….

6. Key Results from three Collaboratives

7. Proportion of partographs completed (vital signs admission ; cervical dilation curve, fetal heart rate with a minimum of two points recorded (1389)

8. Proportion of births for which 3 AMTSL elements performed (Oxytocine given at 1st minute after delivery, Cord traction, uterine fundal massage) (1389)

9. Average compliance with resuscitation standards (1389)

10. Proportion of births in which newborn put to breast within first hour after birth (1389)

11. Proportion of mothers who were monitored post-partum according to standards (1389)

12. CHWs monthly meeting at NK CHC
ANC/PNC Counseling simulation

14. Methodology
Associates in Process Improvement (API)

15. Basics of collaborative improvement
Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care
QI team
representative
Collaborative-level sharing and synthesis of best practices
Site-level summary
Site-level testing of changes
and analysis of results 15 15

16. Keeping Quality Improvement Understood and Active at Different Levels
1- Assisted the MoPH develop strategy for improving quality in health care
2- Assisting the MoPH to establish a structure to implement and oversee
3- Partnering with others to educate
4- Spreading knowledge on quality and exposing leaders to best practices

17. Lead Change Lead Change === Senior Leader Mgmt MoPH Unit Provinces
Improve…Advisors
Lead Change
MoPH Unit
Provinces
Quality Focal Point
Quality Focal Point
Hospitals
===
HFs
Community
QI teams
QI teams

18. Challenges Low wages and therefore low commitment
Out of date/complicated admin procedure
Lack of female staff
Turn over of staff and implementing NGO
Lack of basic needs in HF (supplies, equipment)
Not matching reporting and monitoring system to the extent of expanded services
Security

19. Thank you!