Continuous quality improvement, total quality management, or performance improvement principles cannot be introduced in post-Soviet health systems without putting a foundation in place that will make quality improvement possible. ZdravPlus has supported the restructuring of health systems in Central Asia for the past several years, which has created opportunities to initiate quality improvement at the health provider level. Now ZdravPlus is evolving to help strengthen the new structure and introduce quality improvement techniques by:
To institutionalize improved clinical practice, the countries in Central Asia must develop a comprehensive strategy to integrate the education of all health professionals (physicians, nurses, ancillary, and management personnel) at all levels (undergraduate, graduate, and post-graduate) to produce a more balanced and capable workforce. This workforce will be able to support a high quality and cost-effective primary health care sector. ZdravPlus is working to restructure and strengthen medical education to institutionalize family medicine at undergraduate and postgraduate levels. ZdravPlus is working to deepen and extend the family medicine training-of-trainers program, develop and standardize curricula incorporating evidence-based medicine, and strengthen medical institutes and schools of public health by training trainers and developing curricula.
As the restructuring of health professions education is a long-term process, changes in pre-service training must be complemented by extensive retraining programs for existing practitioners. ZdravPlus continues clinical training activities initiated under ZdravReform to expand and deepen the skill base of primary health care practitioners and integrate services across levels of care. ZdravPlus also is working to introduce a modern, holistic nursing approach and to make nurses an equal member of the primary health care team by expanding nurses' official scope of work (especially with regard to educating and counseling patients), training nurses, and sensitizing and training physicians to the nurses' new role.
Although training methods vary by country, ZdravPlus is developing a set of field-tested, problem-oriented, skills-based training modules that are grounded in internationally accepted best practices. ZdravPlus will continue training family medicine physicians and work to encourage convergence in curriculum content between long-term retraining programs and the modular courses. The goal is to create alternate pathways to become a family medicine physician or nurse - through undergraduate training, one to two year post-graduate training in family medicine, or completion of modular courses over several years. ZdravPlus supports development of a certification process in all countries to ensure that family doctors are recognized within the health system and well qualified. The project also has begun to provide follow-up and supportive supervision after training to monitor quality, performance improvement, and compliance with standards. Both training personnel and supervisors provide ongoing support to health providers, including coaching and technical updates, as well as instilling quality improvement principles, such as customer orientation, teamwork, facilitation and problem-solving to sustain improvements system-wide.
One of the main parameters defining the Soviet quality system is rigid clinical guidelines that are not anchored in evidence-based medicine or best practices, and are applied in a punitive fashion. ZdravPlus is introducing the concept of evidence-based medicine to health professionals by providing access to international literature, training counterparts to analyze relevant literature, and ensuring that all training modules provide rationale for clinical guidelines changes to avoid reversion to established practices after training. ZdravPlus is currently working in Kyrgyzstan, Kazakhstan, and Uzbekistan to facilitate the revision or introduction of new clinical protocols targeted at diseases that are prevalent and currently treated through high-cost, hospital-based protocols. New or revised clinical protocols based on clinical trials and endorsed by WHO and other international organizations will guide primary health care personnel through new diagnostic and treatment methods and will result in cost savings as outmoded and ineffective treatments are replaced. Important examples include childhood illnesses, cardiovascular diseases, tuberculosis, and sexually transmitted infections. ZdravPlus will then support adoption and implementation of the evidence-based protocols into the health delivery system and into pre-service medical training where possible.
ZdravPlus activities in reproductive health and infectious diseases seek to ensure that high quality services are an integral part of primary health care, available to the population close to where they live, with effective referral systems for higher levels of care. Activities center on training doctors, nurses, midwives and others (such as lab personnel) in clinical and counseling skills that meet international standards. The main focus is on training front-line health workers in primary health care facilities. Training is fully integrated with other related activities. Work at the policy level addresses such topics as guidelines for the provision of services, the definition of roles for different categories of health workers, and ensuring that services and related supplies are adequately covered in the emerging financing systems. The project also seeks to ensure the availability and appropriate use of quality drugs and commodities as well as making related information available to health workers and the population. ZdravPlus encourages the countries in Central Asia to avoid strengthening costly vertical systems for reproductive health and infectious diseases, and concentrate on creating a sustainable and integrated health care system to better use limited health resources to provide these important services.
ZdravPlus is implementing Integrated Management of Childhood Illness (IMCI) programs in Kazakhstan, Kyrgyzstan, Uzbekistan, and Turkmenistan to decrease infant and childhood morbidity and mortality from infectious diseases and to encourage proper and timely immunization. These programs include training trainers, training health care providers, supporting community outreach activities, and ensuring a supply of IMCI-related drugs. To avoid creating vertical systems, IMCI protocols are incorporated into primary care services.
In the area of reproductive health, in Kyrgyzstan, ZdravPlus has pilot-tested continuous quality improvement techniques appropriate for Central Asia and is now planning to expand these techniques in Kyrgyzstan and elsewhere. In Uzbekistan, ZdravPlus is working to ensure adequate and sustainable contraceptive supplies and a working logistics and distribution system. In Kazakhstan, ZdravPlus successfully pilot-tested syndromic case management of sexually transmitted infections at the primary health care level and is supporting the Red Apple reproductive health hotline, operated by a local NGO.
In order to properly integrate quality health services into primary health care, many facilities need to be improved. Many donors support facility improvements and equipment in Central Asia, and ZdravPlus helps to facilitate this process by providing technical assistance to develop equipment lists, architectural drawings, and specifications for renovation. It also provides small amounts of equipment or renovation to fill in gaps left by other donors. In addition, ZdravPlus works to improve laboratory capacity at the primary health care level and to ensure that outpatient drugs are available and affordable. In collaboration with the Centers for Disease Control and Prevention (CDC), ZdravPlus is training primary health care practitioners and laboratory workers on the ZdravReform laboratory manual for primary health care. Furthermore, ZdravPlus includes rational pharmaceutical management activities in all components of the project. Activities include developing essential drug lists, formularies, and drug registration and quality control processes; improving drug reimbursement, procurement, and logistics systems; training health practitioners and pharmacists in rational prescribing principles and modern standard treatment guidelines; and including messages about proper use of medications in health promotion activities. Drug information centers are being established to provide reliable information to doctors, pharmacists, and consumers.
As mentioned above, continuous quality improvement systems have been pilot-tested in Kyrgyzstan with plans to roll out working systems within Kyrgyzstan and throughout the region. The system relies on supportive supervision systems - local "curators" assess the quality of services using four tools: client exit interviews, a facility walk-through, curator observation of service provision, and facility self-assessment. Once problems have been identified using these tools, the staff of the family group practice works as a team to prioritize and decide how to solve them. An action plan is developed, with each problem assigned to an individual who has lead responsibility for implementing the solution. Three months later, the curator returns to check on progress and to repeat the cycle.
ZdravPlus continues to implement new facility-level computerized health information systems to collect the data needed to introduce new tools of quality and performance improvement. The project focuses on developing clinical information systems and reports that help primary health care practitioners measure and monitor outcomes and make queries by age, risk factors, region, disease category, and type of referral so that adequate quality monitoring can take place. ZdravPlus also trains primary health care practitioners, health managers, and medical statisticians to analyze facility-level data and use it for decision-making.