This document summarizes the implementation of the Standards Based Management and Recognition (SBM-R) approach to improve quality of child health services in Guinea and Zimbabwe. Key findings include: 1) SBM-R improved health workers' clinical skills and adherence to performance standards, but longer-term impacts on health outcomes were not measured. 2) Implementation lacked consistency with the SBM-R manual and did not sufficiently address health systems support. 3) Recommendations are to better link implementation strength and duration to results, include outcome measures, and adapt SBM-R for low-volume facilities and client perspectives.

1. Improving Quality of Child Health Services
Using the Standards Based Management and
Recognition (SBM-R) Approach in Guinea and
Zimbabwe
Dyness Kasungami,Child HealthTeam Leader,JSI
Serge Raharison,ChildHealthTechnical Officer,JSI

2. Presentation outline
• Introduction
• Basic principles of SBM-R
• Implementation of SBM-R
and results in Guinea &
Zimbabwe
• Discussion of findings,
recommendations and
way forward
Photo source Kate Holt/MCSP and Jhpiego

3. Background
• Quality improvement (for child health services)
• Purpose of the review
• Inform the discussion on quality improvement of child health services
that is responsive to the unique needs of this technical area
• Identify lessons learned from applying SBM-R to child health to inform
its adaptation in countries where it is the preferred approach
• Limitations of the review
• Retrospective review
• Limited involvement of reviewers in implementation

4. What is SBM-R?

5. Child Health SBM-R in Guinea and Zimbabwe
1. Developing and validating the performance standards based on the IMNCI
algorithm
2. Training of supervisor and primary providers in case management of childhood
illness
3. Identifying performance gaps against the performance standards and
developing a plan of action to address the gaps
4. Implementing action plans and self assessments
5. Supervision and coaching of the health care workers who manage sick
children on the use of IMNCI/SBM-R standards
6. Evaluating the performance of the providers against the set IMNCI/SBM-R
standards before training (baseline assessment), and thereafter periodically
7. Recognition event

6. Implementation Guinea Zimbabwe
• Adopted SBM-R for MNH in 2009
and applied in 60 HFs
• CH tested in 3 urban HCs in 3
districts,over 6 months
• All had full cycle of SBM-R for MNH
• 134 standards
• Developed and implemented facility-
level action plans
• Coaching weekly over 4 weeks
• One“external” assessment
• Adopted SBM-R for MNH in 2010
and applied in 17 high-volume HFs
• CH tested in 17 + 4 rural HFs in 2
districts (Manicaland) over 3 years
• 17 HFs had full cycle of SBM-R for
MNH
• 39 (11 + 28) standards
• Developed and implemented facility-
level action plans
• A baseline & 2 “external”
assessments

7. Implementation Guinea Zimbabwe
• 6 standards covered(1) patient flow,
(2) equipment, (3) drugs,(4) supplies,
(5) data quality and use, and (6)
implication in community health
activities.
• The primary output measure is
“individual provider’s adherence to
the IMNCI algorithm.”
• Immediate results indicate a
remarkable improvement in
adherence to performance standards
under observation.
• No standards to improve and
monitor health systems support.
• The primary output measure is
“number of health facilities meeting
at least 60% of the performance
standards.”
• 79% of the 21 HFs met the target
over the two periodic assessments,
comparedto baseline.

8. Results Guinea Zimbabwe
• No outcome measures
• Implementation costs for introducing
MNH standards est.at $4,200 per HF
• Adding child health performance
standards to this existingSBM-R
platform costs on average $2,400 per
HF
• MoH used IMCI as a quality
improvement approach for child
health;need to be convinced about
SBM-R
• No outcome measures
• No information on cost
• MoH adopted SBM-R

9. What is common about the findings?
• Weak link between strength and
duration of implementation (fidelity)
and results,esp.the lack lack of “self-
assessment results”
• Recorded improvement in “correct case
management”
• No “immediate explanation” for
improvement based on dose-response
and lack of comparison with non-SBM-
R implementing HFs
Photo source Karen Kasmauski/MCSP

10. Key Messages
• The implementation of the SBM-R approach in Guinea and Zimbabwe,as
documented,lacks fidelity as described in the Jhpiego SBM-R manual.
• The approach improved clinical skills of HWs and adherence to IMNCI
performance standards under observation.
• There is no information on what motivated the staff to apply the
performance standards.
• Understanding the motivating factors will help in scaling up SBM-R and
potentially other QI/PI approaches.
• The case studies do not demonstrate that this process was led by HF staff
as opposed to outsiders,i.e. supervisors.
• Lack of results on health system support implies “quality” is about HWs.

11. Key Messages,Continued
• Implementation of SBM-R for child health did not include outcome
measures,which is a major limitation on commenting on the success and
impact of the approach on child health indicators.
• Both case studies are based on health facilities with more than one staff
member. Adaptations also need to include applications of the approach to
low-volume/single-staff health facilities.
• The process presents the challenge of negotiating leadership for cross-
cutting areas among project partners.Implementing SBM-R depended on
specialists with their own mandates and time constraints,which left child
health officers in a weak position to lead the process,resulting in delays in
implementation.

12. Recommendations for QI/PIApproaches
• Any QI/PI approach should build on existing approaches to increase the
likelihood of acceptance by health workers and to leverage resources.
• Implementing partners must recognize differences in how services are
delivered for different technical areas and adapt each approach to ensure
that necessary changes are proposed to the flow of services.
• Any QI/PI approach should focus on influencing health outcomes
ultimately at minimum additional cost.

13. Adapting SBM-R for child health
• Standards:Focus on high-impact activities, use a manageable number of
performance standards,and apply weighting of verification criteria in an
effort to recognize gradual improvements
• Results:Define and measure improvements that focus on both processes
and health outcomes
• Implementation:Include monitoring and reporting results from self and
peer assessments as part of routine health management information
systems

14. Adapting SBM-R for child health
• Quality of care:include standards that reflect client perspectives on
quality
• Documentation:participatory design,structured implementation, and
process documentation in an effort to learn and decide what approaches
work in what context and why and sustainability beyond project support
• Cost/cost benefit:collecting data on both the cost of implementation
and possible cost savings resulting from increased adherence to
performance standards in pilot projects and studies

15. Recommendations for MCSP
• MCSP should define roles and
responsibilities for technical areas versus
leadership for cross-cutting areas (like
quality). This will clarify accountability for
quality of work and products of and
timeliness of implementation.
• MCSP should ensure that country teams
develop a single plan for implementing
activities for cross-cutting areas that
clarifies responsibilities and provides both
technical and financial capacity for
implementation.
Photo source Kate Holt/MCSP

16. Way Forward
• Guinea:provided feedback to influence scale-up,especially reducing number
of standards.
• Zimbabwe: under the MCHIP AssociateAward, baseline assessment
should include health system support and outcomes,and better process
documentation.
Under MCSP, we are:
• Conducting a limited review of QI approaches applied to child health.
• Launched a community of practice; engage more with people in the field.
• Developing a tool with “key principles” for QI that will be adapted in each
country to build on what is in place.

17. Questions for discussion?
• What model of quality
improvement works best for
weak health systems?
• How can we create a balance
between project investment to
achieve short term results versus
long term sustainability?
Photo source Karen Kasmauski/MCSP

18. Thank you!

19. For more information,please visit
www.mcsprogram.org
This presentation was made possible by the generous support of theAmerican people through the
United StatesAgency for InternationalDevelopment (USAID),under the terms of the Cooperative
AgreementAID-OAA-A-14-00028. The contents are the responsibility of the authors and do not
necessarilyreflectthe views of USAID or the United States Government.
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