BWH Global Health Equity faculty and PIH colleagues unveil toolkits for costing and mentored quality improvement in resource limited settings

The original version of the article was posted by Partners in Health

In 2009, BWH faculty in the Division of Global Health Equity began a journey with colleagues in Rwanda, at Partners In Health and at HMS, to strengthen community health across the globe. That journey culminated this fall, with the publication of dynamic toolkits on MESH-QI and District Costing Methodology that will allow the impact of this work to endure. Funded by the Doris Duke Charitable Foundation’s Africa Health Initiative, this ambitious work is coming to a successful conclusion and culminating with numerous publications, notably including two powerful toolkits that will allow this work to be replicated at many sites for years to come.

Dr. Lisa Hirschhorn and Dr. Peter Drobac were principal investigators on the Population Health Implementation Training project, which sought to make significant improvements to WHO health system building blocks. The project also worked to fulfill MOH priorities such as improving the quality of health center-based care, strengthening monitoring and evaluation, and enhancing community health worker networks.

Out of this grant and the vision of these leaders, Partners In Health has developed a model for mentoring health care workers. The model is gaining broad attention after improving quality of care in Rwanda and elsewhere for several years. The team also has developed a new guideline—along with a separate, cost-analysis toolkit—that describes how health centers and systems can implement the model, combat the global shortage of quality health care staffing and plan budgets across a range of services.

“Building a culture of high-quality care delivery processes and systems is almost impossible, especially in resource-limited settings,” said Anatole Manzi, director of clinical practice and quality improvement for PIH, who worked closely with Drs. Hirschhorn and Drobac on this project.

“This guide provides invaluable help to organizations and governments preparing to implement MESH-QI as a model for Health Systems Strengthening,” Anatole Manzi, director of clinical practice and quality improvement for PIH.

MESH-QI stands for Mentorship and Enhanced Supervision for Health Care and Quality Improvement. PIH and Inshuti Mu Buzima, as PIH is known in Rwanda, implemented the model in that country in 2010, working with the Rwandan Ministry of Health with funding from the BWH-based grant. Project leaders from BWH, PIH and the ministry quickly saw strong, positive results from the collaborative learning process. MESH-QI includes sending mentors to health centers to give one-on-one, clinical mentorship to less-experienced staff; on-site education sessions; quality improvement coaching; better data collection practices, and engaging in a continuous assessment process to ensure ongoing improvement.

PIH now is promoting and sharing the new “MESH-QI Implementation Guide” online, through the Knowledge Center link on its website. Also posted there is a comprehensive “Costing Toolkit,” which provides a budgetary roadmap for a broad range of services and needs across a health system.

Dr. Jean Claude Mugunga, senior manager of monitoring, evaluation and quality for PIH, and co-author of the Costing Toolkit, said that examples of costing work integrated into health system strengthening principles are uncommon.

“As a result, many policymakers and stakeholders are not fully aware of the flow of resources within the health system and where resource gaps may occur,” Dr. Mugunga said.

The guide offers step-by-step approaches to effective cost analysis, anticipating many of the information gaps that can limit analytic capacity.

Even with notable gains from MESH-QI programs so far, the need for more training programs and collaborative learning remains significant.

A PIH report in 2015 said Rwanda, for example, still had just less than 1 nurse—0.7, to be exact—per 1,000 residents. The report called that rate, “one of the most severe shortages of nurses in the world.”

The World Health Organization recommends that a country have at least 2.3 health care providers—including physicians, nurses and midwives—per 1,000 people. Adding physicians and midwives to Rwanda’s data brings the country’s rate to just 0.84 care providers per 1,000 people, according to the report.

Implementing MESH-QI can address staffing challenges in a variety of areas. PIH sites have applied MESH-QI to treatment practices for HIV, non-communicable diseases, mental health, maternal and child health, and more—and the model is expanding well beyond Rwanda.

“We definitely have a MESH program here,” said Dr. Emily Wroe, DGHE faculty member and clinical director for Abwenzi Pa Za Umoyo, as PIH is known in Malawi. “It’s been up and running in a really significant way on malaria for a long time.”

Wroe said APZU’s use of MESH-QI includes mentoring and training programs to improve treatment of malnutrition and maternal health, with mental health applications planned for the near future. “It’s become a tool that we’re using in a lot of different programs,” Wroe said.

Another example of MESH-QI principles in action is the All Babies Count program, which Inshuti Mu Buzima began with the Rwanda Ministry of Health in 2013. The program focuses on improving health care for mothers and infants before, during and after delivery.

After pilot efforts proved effective from 2013-15, PIH and Rwanda’s health ministry now are scaling the program nationally, with a goal of supporting 76 new health facilities, training more than 300 health care providers and serving a population of more than 1.8 million—all with the goal of reducing newborn mortality by at least a third by 2019, according to a PIH summer newsletter.

“We organize learning collaboratives that include clinicians such as doctors, nurses and midwives, as well as non-clinical staff such as data managers and administrative personnel, and also government officials,” the newsletter states, describing the program. “These learning collaboratives create a community to review recent data, develop quality improvement projects focused on improving key indicators, and share successes and challenges.”

Dr. Alishya Mayfield, division faculty member and senior clinical adviser on strategy for PIH, said All Babies Count “is an innovative use of the MESH model, which strengthens clinical care for mothers and infants by improving mentorship of nurses, and by giving clinicians more ownership of quality improvement initiatives in the health care facilities in which they work.”

Authors and supporters of the new MESH implementation and costing guides hope such innovative uses and expansions continue. The guides were created with support from MESH-QI mentors, clinicians, and technical advisors; district hospital leadership in Rwanda; and the Doris Duke Charitable Foundation’s African Health Initiative.

The MESH-QI Toolkit offers a stepwise approach to preparation, implementation, and assessment.


“Toolkits such as these allow an opportunity to replicate best practices without excessive cost,” said Jennifer Goldsmith, director of administration for the Division of Global Health Equity at Brigham and Women’s Hospital, and lead editor of the toolkits. “PIH can facilitate programs at our own sites and share our learning with partners with a level of detail and guidance that differs from past publications. This approach will allow our learning to endure and our approach to expand, improving care delivery where it is most needed.”