ASSIST (Applying Science to Strengthen and Improve Systems) is a new five-year project of the Office of Health Systems in the USAID Global Health Bureau which focuses on improving health care, strengthening health systems, and advancing the frontier of improvement science. The overall objective of the ASSIST Project in Botswana is to foster improvements in health care processes through the application of modern improvement methods by Ministry of Health (MOH) providers and managers. Through this project the PEPFAR team aims to build the capacity of the Botswana MOH systems to improve the effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the maternal and neonatal services they provide. In addition to supporting the implementation of improvement strategies, the project seeks to generate new knowledge to increase the effectiveness and efficiency of applying improvement methods.

Maternal and neonatal mortality reduction was chosen as the subject for this QI project because: 1) HIV is a large contributor to maternal deaths in Botswana; 2) maternal mortality reduction is the top priority of the Ministry of Health, 3) maternal and neonatal mortality reduction is in line with the Global Health Initiative, and; 4) improving ANC, PMTCT and HIV-free child survival will advance PEPFARs goal of an AIDS-free generation for Botswana. Work began in 2012 and intense activity is to be conducted in the second half of 2013 and continue to 2015 in order to reach the MDG target. Funds will be used to cover full-time national program leader for this activity and intensive technical assistance from the ASSIST project headquarters at the URC. We will taper off funding in 2014 and expect the MOH to achieve its goal and complete the project in 2015.

A strong health system is one which can reliably deliver the right services at the right time to patients as they need them. Quality improvement is an important component of building a strong health system because it provides health workers with the skills to identify where they are failing to provide the right services, identify the reasons for gaps, and test solutions until they are able to provide care which is responsive to patients needs.

Most quality improvement work happens at the level where patients and providers meet. Because of this, there is a need for facility-based quality improvement teams that are supported to do improvement work in line with ministry priorities. ASSIST will work with the ministry to set up mechanisms to provide support to facility level improvement teams to reduce maternal and neonatal mortality.

One third of women who give birth in Botswana are HIV positive. In a recent review of maternal deaths*, 64% of the women who died were HIV positive, 38% were on HAART, and 21% had clinical AIDS. HIV was the main cause of death in 34% of cases. More women died of indirect causes than direct obstetric causes and more HIV positive women died of these indirect causes. One of the reasons for this appears to be poor linkages between HIV and antenatal care. HIV treatment and monitoring are carried out by outpatient infectious disease clinics while pregnancy is managed by antenatal clinics as separate processes. Parameters for monitoring HIV progression, such as weight, clinical symptoms and CD4 counts were often not recorded on ANC records. One of the key elements of this project will be to ensure that all women get the routine ANC and delivery care they need, including HIV care and PMTCT services, and that these services are fully integrated and linked. This project will also facilitate late and repeat testing of women to identify those infected late in pregnancy, which leads to both maternal and infant morbidity/mortality.

Another key component of this project will be to improve post partum care. Many women in Botswana are discharged within 12 hours of delivery with no follow up. In the review mentioned above, 52% of the deaths occurred in the post natal period. Forty-one percent (41%) of these women had AIDS and 14% with possible ARV complications. By strengthening post partum care, this project will ensure that exposed mothers and infants remain in care to get the attention they need for their own survival and to prevent transmission to the infant during the breastfeeding period. The dual focus on mothers and newborns will also give us an opportunity to reinforce the best infant feeding practices including exclusive breast feeding for the first six months.

The ASSIST Project advisors will work with the MOH Quality Improvement (QI) Task Team to implement the quality improvement plan developed in 2012. The priorities include: developing mechanisms to involve senior leadership in improvement activities; building a system and structure throughout the MOH to support facility level improvement activities; developing a monitoring system for improvement activities; developing an approach for building improvement skills among health workers and managers. The QI project aims to reduce maternal mortality (MM) from 160 to 80 per 100,000 live births in order to reach the maternal mortality MDG for Botswana of reducing the MM ratio of 1991 of 326 deaths per 100,000 live births by three quarters. see library doc