defined as strategies to improve the delivery of effective interventions, have long been used in high-income countries to improve health care and outcomes, but their application to middle- and low-income countries has been more recent. In 2007 the World Health Organization identified quality as a key component of improved health outcomes and greater efficiency in health-care service delivery. As more countries adopt QI approaches there is a need to document their implementation and effectiveness. Most of the currently published literature on assessments of QI approaches in middle- and low-income countries has focused on determining changes in process indicators, perceptions of change or improvements in hospital management. While understanding the implementation of QI approaches is crucial, so is evaluating their impact on health outcomes. This paper presents an evaluation of the first phase of a large QI project in Ghana.
Project Fives Alive! is a QI intervention implemented by the National Catholic Health Service of Ghana and the Institute for Healthcare Improvement (IHI) in close collaboration with the Ghana Health Service (GHS). Project Fives Alive! began in July 2008 with a pilot phase and will scale up to all public and faith-based health facilities in Ghana before the project end date of March 2015. The project aligns itself closely with the High Impact Rapid Delivery (HIRD) program for maternal and child health, a national program launched by the GHS in 2006. The HIRD program is focused on delivering low-cost maternal and child health and nutrition interventions nationwide. Using QI methods and tools, the project aims to improve health outcomes in mothers, infants and children under-five by improving the coverage, quality, reliability and patient centeredness of the HIRD program across all public and faith-based facilities in Ghana. Thus, the project aims to assist and accelerate Ghana's national effort to reach both Millennium Development Goal 4 (a two-third reduction in under-five mortality from 1990 to 2015) and Millennium Development Goal 5 (a three-quarter reduction in maternal mortality from 1990 to 2015). In 2008, under-five mortality was estimated to be 80/1000 live births and maternal mortality was estimated to be 350/100,000 live births.
The project's QI theory is based upon the model for improvement whereby process failures are identified, and simple and low-cost change ideas are tested in the facilities and the communities which they serve. The improvement approach emphasizes systems thinking, analysis and learning from data at the local level. The project incorporates the IHI's Collaborative Model for Achieving Breakthrough Performance whereby health staff and management teams within a district are brought together to form an Improvement Collaborative Network (ICN). Within an ICN each facility forms a QI team which is responsible for overseeing the development and testing of change ideas. Members from each facility's QI team attend four learning sessions, structured workshops led by Project Fives Alive! staff, every 4 months to learn QI methods and to share progress with other QI teams. Another key aspect of the approach is coaching visits to the health facilities made by project staff in conjunction with district health supervisors. These coaching visits take place during activity periods, the 4-month long periods following each learning session. A detailed description of the project's methodology and implementation strategy is presented by Twun-Danso et al.
This paper is focused on evaluating the pilot phase of Project Fives Alive! from July 2008 to December 2009, which included 27 facilities in 4 largely rural districts/dioceses in Northern Ghana. The particular districts were chosen because they included an even mix of government and Catholic facilities. The facilities included 25 health centers (staffed by midwives, nurses and other health staff but not doctors) and 2 hospitals, which provided comprehensive emergency obstetric and neonatal care. This phase of the project was intended to identify a package of locally tested, successful change ideas that could be rapidly scaled up nationally in the later phases of the project.