Niger QAP/BASICS joint project final evaluation

The 1997 merger of QAP and BASICS in Niger led to a new and important way of implementing integrated management of childhood illness (IMCI), one that starts by bolstering IMCI support systems rather than with IMCI training. It also succeeded in bringing many improvements to the health care system in the target areas. Key findings are as follows: (1) The joint project achieved over 90% of its objectives and in some cases exceeded expectations. (2) The merger of QAP and BASICS reduced costs and led to benefits on the local, regional, national, and international levels by applying QA measures to support the introduction of IMCI. (3) The QAP/BASICS project has trained 400 health workers in quality assurance skills. At the time of the evaluation, over 77 quality improvement teams had formed and had worked on about 120 problem-solving cycles in areas such as prenatal care, family planning, immunization coverage, and nutritional rehabilitation. (4) The project introduced a number of management tools that contribute to the support of IMCI. The new management framework used by health care workers and their managers provides indicators and a new management environment for health organizations by allowing health workers to change their behavior and improve their performance. Staff motivation and interest increased through team activities and the task follow-up process. (5) QAP/BASICS revived the supervisory system and created trained supervisory teams who can provide technical support to health facility staff. The concept of coaching facilitated the transformation of supervision from an authoritarian style to a supportive, problemsolving approach. (6) The project introduced a number of tools that contributed to IMCI's introduction. The use of the Rapid Performance Assessment of Health Workers (ERPA) tool proved valuable not only in monitoring health workers' performance, but also in improving it through the timely feedback of IMCI compliance data. Also, the integrated supervision checklist is a helpful, comprehensive tool, albeit too long. (7) The problemsolving tool elevated the health providers' ability to identify and solve problems in health service delivery. However, this tool cannot detect defects in clinical skills, which must be addressed through supervision. The project has also had a great impact in improving the staff's ability to collect, analyze, and use data at the health facility and district levels. (8) Improved stockkeeping of essential generic drugs, combined with cost recovery, resulted in lower cost, more reliably available essential generic drugs (MEG), which stimulated the continuity of care and activity integration. The main factors limiting QA were: personnel mobility and motivation; old refrigerators, maintenance problems, gas shortages, and an unreliable car/motorbike pool; inaccurate or out-of-date demographic data; the dispersed nature of the population; lack of uniform clinical standards; unmet salary payments; and time spent away from the center to attend training sessions. Overall, the project enabled Niger to take a leadership role in introducing IMCI in the West African region. Individuals from many West African countries have participated in IMCI training in Niger, and Niger's experience in QA and IMCI was presented at a number of regional conferences and meetings. Considering the large number of trained agents and trainers, prepared materials, existing documentation, and the success of the international conference in Niamey in 10/98, the project's replication in Francophone Africa should be rapid and could spread to other continents. The launch of the supervision system and the efficient use of the supervision check-list, ERPA management and analysis, and the coaching methods were important experiments that have been field tested and should benefit other QA projects in Latin America and Asia. Includes lessons learned.