By Lydia Gahimbare, Tharcissie Aimée Maniraguha, Fabrice Kakunze, and Léon Ndayizeye, MOMENTUM Private Healthcare Delivery, Burundi; with contributions from Erin Files Dumas and Mariela Rodríguez, MOMENTUM Private Healthcare Delivery

In Burundi, the private and faith-based healthcare sector has the potential to help improve key health indicators through increasing quality coverage of health services and reducing delays in obtaining care. Burundi’s most recent Demographic and Health Survey (DHS) demonstrated that 16% of women who used a modern contraceptive method obtained it from a private source. The DHS also indicates that of the 84% of births attended by providers in health facilities, an average 14% of those births occurred in private health facilities.¹ With its important role within Burundi’s healthcare system, it is paramount that the private sector offer high quality services to its clients. It is within this context that MOMENTUM Private Healthcare Delivery in Burundi focuses on strengthening family planning (FP), reproductive health (RH), malaria, and maternal, newborn, and child health (MNCH) services in the private sector.

Standards of Quality of Care

Part of MOMENTUM’s approach to service delivery includes training, supervision, coaching, and periodic assessment of private sector health providers in quality of care standards. As the prime implementing partner, Population Services International (PSI) leverages its Quality of Care Framework (Box 1), which is adapted from the globally recognized Bruce-Jain Quality Framework, as the guiding principles for quality service delivery. Project supervisors continually coach and supervise newly trained providers to ensure their adherence to five quality of care domains. As part of efforts to monitor the quality of FP/RH/MNCH services, the project conducts annual quality of care assessments in a sample of supported health facilities to objectively review if services are people-centered and delivered safely, equitably, and efficiently. The assessments are led by either external evaluators (with evaluators from other PSI countries) or by internal evaluators (made up of the MOMENTUM team in-country).

Collaborating with Local Partners to Conduct the 2023 Quality of Care Assessment

MOMENTUM works with two local partners: Association Nationale des Franchise Sociale (ANFS) and Reseau des Confessions Religieuses pour la Promotion de la Sante et le Bien Être Integral de la Famille (RCBIF). The project uses a ‘learning by doing’ approach to strengthen the technical capacity of these organizations.  The partnership aims to build the organizational capacity of both local organizations as they ready themselves to independently manage donor funds in the future. In November 2023, MOMENTUM in Burundi modified the PSI-led assessment approach to include the participation and leadership of local partners within the evaluation team. ANFS and RCBIF’s participation in the assessment served as an important milestone in their progress toward strengthened technical capacity.

The assessment included two four-person teams of evaluators from MOMENTUM, ANFS, RCBIF, and Burundi’s Ministry of Health. Each team assessed and scored six health facilities, for a total sample of twelve facilities. While ANFS and RCBIF regularly conduct routine supportive supervision, the 2023 assessment was the first time these local partners participated as lead members of the MOMENTUM project’s annual quality of care assessment. For both partners, this presented an opportunity to identify the sample of sites, utilize the assessment tools, analyze and interpret the results, and objectively score the sample based on the assessment criteria.

Thirty-three quality of care standards were evaluated in the sample sites—resulting in an average score of 82/100 for the assessment. While these results are positive for the quality of services at MOMENTUM-supported facilities, the knowledge and skills obtained through this activity also have meaningful implications and outcomes for localization and the leadership of MOMENTUM’s local partners:

• First, this activity demonstrated a shift from the evaluated to the evaluator. While ANFS had some prior experience of its health facilities being evaluated within the framework of a donor-funded project, this was RCBIF’s first experience participating in a quality of care assessment. Further, the shift in having the partners themselves lead as evaluators was a key step in progressing in and building toward their technical and organizational capacity around quality of care.
• Second, active participation in the assessment—while just one step and one component of continuous quality of care— demonstrated the need for the partners to understand and own the assessment tools. Through the assessment, the partners gained a collective understanding of how MOMENTUM’s quality of care approach was functioning in supported facilities and how certain standards can be adapted to improve training and assessments in the future. Dr. Claudia Kaneza of RCBIF shared, “… We found that some of the standards set out in the quality of care assessment scorecard criteria are not applicable to our national context [such as criteria around self-injectable FP methods] …This observation underlines the need to adapt assessment tools to the specificities of our country.”
• Third, while the capacity and ability to understand and conduct the assessment is critical, projects working with local partners should understand and appreciate what motivates local partners to take on this work. Many local organizations in Burundi do not work directly with health facilities; this aspect is distinct for RCBIF and ANFS who directly supervise 40 health facilities across all regions of Burundi. The knowledge and skills gained not only lead to improved technical capacity in quality of care assessments, but in the organizational capacity of the local partners to offer a unique value-add in their work with private health facilities.

A Holistic Approach to Quality of Care

Conducting quality of care assessments is just one, albeit important, component to ensuring a holistic approach to quality of care in the private sector. While ANFS and RCBIF operationalized skills to conduct the quality of care assessment, there are other critical steps to ensure continuous quality improvement. For example, the preparation and design for the evaluation which includes the development of agendas, engagement with the Ministry of Health, and communications with the health districts. While these are logistical steps, they are key to conducting assessments. Attaining these additional skills is part of the broader quality improvement process and is a way to hone skills around external engagement and coordination. These activities marry the organizational and technical capacities that are necessary to ensure continuous quality improvement.

In addition to the pre-work for the assessment, developing an operational plan after the assessment addresses any issues or gaps. Although PSI has historically developed and monitored the post-assessment follow-up plans, local partners ANFS and RCBIF are now leading on this action and owning this important component to continuous quality care.

The efforts to improve quality of care within MOMENTUM and the leadership of ANFS and RCBIF have been a positive experience for both local partners. Dr. Claudia Kaneza of RCBIF shared that she was “keen to master the whole evaluation process. I took part in the training with interest, and in the field, I was exposed to quality evaluation tools as well as the methodology for conducting the evaluation. This experience enabled me, as a young evaluator, to understand the extent to which a well-conducted evaluation can reflect the impact of a project’s activities. It also made me aware of the importance of mastering evaluation tools to ensure the success of this approach. Thanks to this experience, I now feel sufficiently prepared and confident to initiate and lead similar work within RCBIF.”

Similar sentiments were shared by Dr. Safi Hakizimana from ANFS, “As a trainee assessor, I took part in various stages of this activity: from preparation to the assessment itself, and in the briefing and debriefing. I had the opportunity and good fortune to have access to evaluation tools, to master them, and to assimilate the methodology to be used. All this enabled me to become autonomous in carrying out the internal assessment.”

Learning and Adapting to Improve Local Capacity for Quality

As MOMENTUM in Burundi continues to support the transfer of project responsibilities to local partners RCBIF and ANFS, the quality of care assessment amplifies the opportunities and benefits of jointly conducting activities that have been routinely run by prime implementing partners. Local partners are leading in the replication, adaptation, and monitoring of certain tools and activities like quality of care assessments.

Strengthening ANFS’ and RCBIF’s assessment skills will continue as quality of care is a continuous and multi-step approach. The project will support local partners in all aspects of quality of care, which is not limited to the assessments, but also includes the interpretation of assessment findings, analysis, and supportive supervision. ANFS and RCBIF continue to strengthen their technical and organizational capacities to increase sustainability of quality services, impact, and infrastructure in the private sector of Burundi.