Institutionalizing Quality Improvement in Tanzania: A review and a look forward

However, these mid-level managers face competing priorities, limited budget, and other challenges to effectively support facilities in their geographies. The Government of Tanzania recently began working to strengthen accountability systems for QI at the council level by selecting a district focal person for QI to be part of the district health technical team. The USAID Applying Science to Strengthen and Improve Systems (ASSIST) project in Tanzania was tasked with supporting the President's Office - Regional Administration and Local Government (PO-RALG), Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) and Walter Reed Army Institute of Research (WRAIR) team to enhance capacity of RHMT/CHMTs in 19 councils in three regions of the Southern Highlands of Tanzania to manage and lead QI efforts. The focus was on building R/CHMT teams as effective coaches who could in turn support the facility QI teams. ASSIST collaborated with the Henry Jackson Foundation (HJF) to conduct four skill-building sessions for 45 mid-level managers (29 female, 16 male) from R/CHMTs in these regions including two learning sessions and three practical orientation coaching visits. Between May and July 2018, R/CHMTs from all 19 councils conducted at least two coaching visits to supported facilities using council funds. This was the first time that councils had funded QI coaching visits in these 19 councils. ASSIST also developed a coaching guide for the teams to use as a reference when supporting frontline QI teams in improving the quality of HIV care. The objective of this assessment is to examine the process and results of building capacity among these mid-level managers as a function of institutionalizing QI at the council and regional levels. Findings from this assessment will complement the knowledge products being developed by USAID ASSIST. Between baseline and end line, mid-level managers reported an improvement in their self-assessed understanding of QI methods. At baseline, none of the 28 mid-level managers surveyed felt they were well developed in all of the skills related to QI methods and tools, and all but one self-assessed themselves as needing “a lot of development” in at least one of the QI methods at tools. At end line, respondents showed a higher level of confidence in facilitating and leading QI teams, motivating and giving opportunities to QI team members, understanding how the culture of a workplace influences quality of care, and building confidence of QI team members. R/CHMTs who participated in an end line interviews reported providing facility QI teams with support in managing the QI team process, and providing technical assistance for QI and in monitoring and use of data for decision making. They also reported intentions to continue providing this support following the end of ASSIST. Fewer respondents indicated they shared results and lessons learned across facilities, in part due to short duration of the intervention; however, all had intentions to do so in the future. At facility level, challenges around funding persisted. There was room for improvement in participating in shared learning opportunities and ensuring new staff were educated in improvement. Despite these challenges, all facilities were tracking QI indicators and reporting them to the district and regional levels, QI team members had clear understanding of QI roles and responsibilities, and had copies of national QI documents. Additionally, seven facilities had spread the use of improvement methods to areas beyond HIV, indicating a level of comfort with QI. Mid-level managers can provide coaching support to facilities in improving the quality of care in Tanzania. The capacity building efforts of ASSIST have shown positive results in enhancing the skills and knowledge of mid-level managers in QI methods and tools. However, challenges persist, particularly around funding and shared learning opportunities. To sustain the gains made, it is essential to continue providing support to mid-level managers and facilities in implementing QI activities.