Introduction

The goal of quality improvement (QI) is quite simple -- to make something better. The application of the QI approach for a particular improvement area is manifested in an organized and continuous cycle of deciding on a change to test, using quantitative measures to assess if that change resulted in improvement, and using those data to decide whether to adopt, adapt, or move on to another change idea.

In healthcare, QI is a structured effort to improve clinical and service delivery processes -- led by front-line staff -- with the objective of optimizing health systems that are conducive to improving health outcomes. Health facilities and hospitals the world-over struggle with inconsistent and inaccurate data, inefficient clinic flow, long patient wait-times, lack of equipment and treatment options, and understaffing. The potential of the QI approach is also universal -- we have seen QI principles successfully applied to health systems in developing countries as evidenced by the many accomplishments and lessons documented to date from successful interventions in many of those countries (1, 2). QI translates across broad primary healthcare areas like maternal, neonatal and child health (MNCH), nutrition and HIV prevention, treatment and care.

When a group of global and country stakeholders convened in 2012 to form the Partnership for HIV-Free Survival (PHFS) under the auspices of the US President’s Emergency Plan for AIDS Relief (PEPFAR), the UN World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), QI was the chosen implementation and collaborative learning approach for accelerating, improving, and ultimately scaling up existing prevention of mother-to-child HIV transmission (PMTCT) implementation strategies in the six sub-Saharan African countries – Kenya, Uganda, Tanzania, Mozambique, Swaziland, Lesotho and South Africa -- that made up the Partnership. The work of the Partnership was guided by the WHO PMTCT guidelines recommending lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and breastfeeding women (Option B+). The goal of the PHFS was to keep HIV-positive pregnant women and mothers alive, treatment-adherent, and in care, and to keep their HIV-exposed infants alive, nourished, in care, and HIV-free. For five years, the Partnership worked in a limited number of demonstration sites in each country, documenting and sharing their learning at the district, national and global levels.

This nine-paper supplement describes the design and startup phase of the PHFS, QI approach, country results and accomplishments, and the way in which learning was documented and shared within the Partnership and with the global health community at-large. Several PHFS countries recorded vast process improvements in various areas, including ART initiation for newly-diagnosed pregnant and lactating women, ARV prophylaxis and age-defined HIV testing for exposed infants, exclusive and extended breastfeeding of infants, and retention of mother-baby pairs in comprehensive PMTCT care up to two years postpartum. And, Uganda’s PHFS sites demonstrated an increase in the percentage of babies being discharged from PMTCT programs with an HIV-free diagnosis at 18 months of age. Several of the PHFS countries have institutionalized key practices that were tested and proven effective during the demonstration phase, and maintain committees and partnerships that were established or strengthened through the PHFS experience.

The global health community has made tremendous progress using QI to improve healthcare processes, within the PHFS and beyond. However, I believe that we have barely scratched the surface of process improvement and nowhere is its potential greater than in developing countries that face chronic understaffing and other resource limitations. There is an enormous amount of work to be done for the potential of healthcare systems to be fully realized, but the PHFS experience provides some insight on the path to be taken.

Dr. James Heiby, MD, MPH
Former Agreement Officer’s Representative, USAID ASSIST Project, U.S. Agency for International Development