A new study from Africa Health Research Institute (AHRI) shows that applying continuous quality improvement (CQI) methods to primary healthcare contexts can significantly improve the quality of care in rural South Africa.

The work is published in the scientific journal, PLOS Medicine.

The study, titled ‘The impact of continuous quality improvement on coverage of antenatal HIV care tests in rural South Africa: Results of a stepped-wedge cluster-randomised controlled implementation trial’ was a collaborative project between the Department of Health (uMkhanyakude District), Africa Health Research Institute (AHRI), and the University of KwaZulu-Natal (UKZN) with the main goal to identify even better approaches of ensuring that pregnant women do not pass on HIV to their unborn children.

The research team aimed to establish the effectiveness of CQI on two essential HIV services for pregnant women – viral load monitoring for pregnant women living with HIV and repeat HIV testing for pregnant women not living with HIV. For pregnant women who had initially been found to be HIV negative, the aim of the CQI intervention was to identify HIV seroconversion during pregnancy to ensure effective treatment and elimination of mother-to-child transmission of HIV.

“The methods of continuous quality improvement are global in nature, however what is done with these methods is completely locally determined,” explained senior author and AHRI Faculty Member, Professor Till Bärnighausen. “The continuous quality improvement intervention automatically takes local cultures and resources into account because the nurses in the clinics determine how they use this approach. This intervention is adaptable to almost any health systems context, health systems function, and disease domain. It is often very meaningful to go ‘function by function’ in the health system when improving quality of care. Here, our function was HIV-related monitoring and testing in antenatal care.  Other functions could be, for example, TB care, hypertension screening, or diabetes treatment.”

For the study, the researchers assigned seven public-sector primary care clinics in rural northern KwaZulu-Natal to receive CQI in random sequence. Each intervention was delivered by a trained team of local CQI mentors, who worked collaboratively with clinic staff. Each of the seven clinics used the study’s main ‘toolbox’ for quality improvement, which was provided by quality improvement mentors. Each clinic then decided for themselves – depending on their circumstances and resources – what their priorities were and how they wanted to implement a system of quality improvement.

The researchers found that the CQI intervention increased HIV viral load monitoring by nearly 40%. However, it did not improve repeat HIV testing for HIV negative women. The latter may be because many of the health workers perceived viral load monitoring to be more important for health outcomes than repeat HIV testing.

“This project proves that CQI can be effective at improving the quality of primary care in resource-poor communities. But it can also fail. Future research should be done to better understand under what conditions and for which health system functions CQI will succeed,” said Bärnighausen.

Read the open-access paper here

Top photo: Ben Gilbert/Wellcome