BackgroundStrategies to identify and treat undiagnosed prevalent cases that have not sought diagnostic services on their own, are necessary to treat TB in patients earlier and interrupt transmission. Late presentation for medical services of symptomatic patients require special efforts to detect early and notify TB in high risk populations. An intervention that combined quality improvement with facility-led active case finding (QI-ACF) was implemented in 10 districts of Northern Uganda with the highest TB burden to improve case notification among populations at highest risk of TB.MethodsUsing QI-ACF intervention approach in 48 facilities, we; 1) targeted key vulnerable populations, 2) engaged district and facility teams in TB systems strengthening, 3) conducted systematic screening and diagnosis in vulnerable groups (people living with HIV, fishing communities, and prisoners), and 4) trained health workers on national x-ray diagnosis guidelines for smear-negative patients. Facility-led QI-ACF meant that health care providers identified the target population, mobilized and massively screened suspects, and addressed gaps in documentation. Chest X-ray diagnosis was promoted for smear-negative TB among those suspects whose sputum examination was negative. The effect of the intervention on case notification was then assessed separately over the post intervention period.ResultsOver all TB case notification in the intervention districts increased from 171 to 223 per 100,000 population between the baseline months of October–December 2016 and end line month of April–June 2017. TB patient contacts had the majority of TB positive cases identified during active case finding (40, 6.1%). Fishing communities had the highest TB positivity rate at 6.8%. Prisoners accounted for the lowest number of TB positive cases at 34 (2.3%).ConclusionTargeting should be applied at all levels of TB intervention to improve yield: targeting districts and facilities with the lowest rates of case notification and targeting index patient contacts, HIV clients, and fishing communities. Screening tools are useful to guide health workers to identify presumptive cases. Efforts to improve availability of x-ray for TB diagnosis contributed to almost half of the new cases identified. Having all HIV patients who were eligible for viral load provide sputum for TB screening proved easy to implement.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3786-2) contains supplementary material, which is available to authorized users.

Saving Mothers, Giving Life (SMGL) strengthened the health system in 7 districts in Northern Uganda through a quality improvement approach. Quality improvement teams removed barriers to delivering maternal and newborn health services and improved emergency care, reducing preventable maternal and newborn deaths in a post-conflict, low-resource setting.

Modern quality improvement approaches enabled hospital staff to analyze barriers and identify solutions for ''how'' to integrate family planning into postpartum care. Private spaces for postpartum family planning (PPFP) counseling, along with involving husbands and mothers-in-law in counseling, substantially increased the percentage of women receiving PPFP counseling and their preferred method before discharge. Self-reported pregnancy was also significantly lower up to 18 months post-discharge compared with women receiving routine services. ABSTRACTTo address low contraceptive use in Afghanistan, we supported 2 large public maternity hospitals and 3 private hospitals in Kabul to use modern quality improvement (QI) methods to integrate family planning into postpartum care. In 2012, QI teams comprising hospital staff applied root cause analysis to identify barriers to integrated postpartum family planning (PPFP) services and to develop solutions for how to integrate services. Changes made to service provision to address identified barriers included creating a private counseling space near the postpartum ward, providing PPFP counseling training and job aids to staff, and involving husbands and mothers-in-law in counseling in person or via mobile phones. After 10 months, the proportion of postpartum women who received family planning counseling before discharge in the 5 hospitals increased from 36% to 55%, and the proportion of women who received family planning counseling with their husbands rose from 18% to 90%. In addition, the proportion of postpartum women who agreed to use family planning and left the hospital with their preferred method increased from 12% to 95%. Follow-up telephone surveys with a random sample of women who had received PPFP services in the 2 public hospitals and a control group of postpartum women who had received routine hospital services found significant differences in the proportion of women with selfreported pregnancies: 3% vs. 15%, respectively, 6 months after discharge; 6% vs. 22% at 12 months; and 14% vs. 35% at 18 months (P , .001). Applying QI methods helped providers recognize and overcome barriers to integration of family planning and postpartum services by testing changes they deemed feasible.

Quality problem or issueWhen the Ministry of Public Health (MoPH) of the Islamic Republic of Afghanistan began reconstructing the health system in 2003, it faced serious challenges. Decades of war had severely damaged the health infrastructure and the country's ability to deliver health services.Initial assessmentA national health resources assessment in 2002 revealed huge structural and resource disparities fundamental to improving health care. For example, only 9% of the population was able to access basic health services, and about 40% of health facilities had no female health providers, severely constraining access of women to health care. Multiple donor programs and the MoPH had some success in improving quality, but questions about sustainability, as well as fragmentation and poor coordination, existed.Plan of actionIn 2009, MoPH resolved to align and accelerate quality improvement efforts as well as build structural and skill capacity.ImplementationThe MoPH established a new quality unit within the ministry and undertook a year-long consultative process that drew on international evidence and inputs from all levels of the health system to developed a National Strategy for Improving Quality in Health Care consisting of a strategy implementation framework and a five-year operational plan.Lessons LearnedEven in resource-restrained countries, under the most adverse circumstances, quality of health care can be improved at the front-lines and a consensual and coherent national quality strategy developed and implemented.

BackgroundDespite the conventional approaches to HIV prevention being the bedrock for early reductions in HIV infections in Uganda, innovations that demonstrate reduction in risk to infection in vulnerable populations need to be embraced urgently. In the past 2 years, a USAID-funded project tested a quality improvement for behavior change model (QBC) to address barriers to behavioral change among adolescent girls and young women (AGYW) at high risk of HIV infection. The model comprised skills building to improve ability of AGYW to stop risky behavior; setting up and empowering community quality improvement (QI) teams to mobilize community resources to support AGYW to stop risky behavior; and service delivery camps to provide HIV prevention services and commodities to AGYW and other community members.MethodsWe recruited and followed a cohort of 409 AGYW at high risk of HIV infection over a 2-year period to examine the effect of the QBC model on risky behaviors. High-risk behavior was defined to include transactional sex, having multiple sexual partners, and non-use of condoms in high-risk sex. We documented unique experiences over the period to assess the effect of QBC model in reducing risky behavior. We analyzed for variances in risk factors over time using repeated measures ANOVA.ResultsThere were statistically significant declines in high-risk behavior among AGYW over the QBC roll-out period (p < 0.05). Univariate analysis indicated reduction in AGYW reporting multiple sexual partners from 16.6% at baseline to 3.2% at follow up and transactional sex from 13.2 to 3.6%. The proportion of AGYW experiencing sexual and other forms of gender based violence reduced from 49% a baseline to 19.5% at follow up due to the complementary targeting of parents and partners by QI teams.ConclusionThe QBC model is appropriate for the context of northern Uganda because it provides a framework for the community to successfully drive HIV prevention efforts and therefore is recommended as a model for HIV prevention in high-risk groups.