Creative Solutions: A Case Study of Improving Health Care in the Russian
Federation
M. Rashad Massoud, MD, MPH, FACP
Director, USAID Applying Science to Strengthen and Improve Systems Project
Senior Vice President and Quality and Performance Institute,
University Research Co. LLC.
Amanda Ottosson, MSc
Healthcare Improvement Fellow, USAID Applying Science to Strengthen and Improve Systems Project
Quality and Performance Institute,
University Research Co. LLC.
This work was done under the Quality Assurance Project implemented by University Research
Co. LLC., funded by the United States Agency for International Development (USAID).
INTRODUCTION
This activity was born as a result of a shared vision to introduce modern improvement methods in
order to improve quality of care and promote evidence based practices held by the US and Russian
leadership of the Health Committee of the US-Russia Joint Commission for Economic and
Technological Cooperation. The Russian Ministry of Health identified the Central Public Health
Research Institute (CPHRI) in Moscow and Tula and Tver Departments of Health as the Russian
implementation counterparts for the activity. The priorities for improvement were identified as
maternal and child health (MCH), specifically in pregnancy-induced hypertension (PIH) and
neonatal respiratory distress syndrome (NRDS) as well as primary care, specifically hypertension.
In 1998, facilities representing the different levels and types of health care settings were initially
chosen to participate in the improvement demonstration phase. The smallest number of facilities,
which represented different levels of care were chosen. Five facilities were chosen for
hypertension, three for pregnancy-induced hypertension, and five for neonatal respiratory distress
syndrome.
Results in the demonstration phase showed significant improvements in the care provided to
patients, such as a reduction in early neonatal mortality for Tver Oblast 1 from 10.3 per 1,000 to
4.8 per 1,000; significant cost savings due to waste reduction, such as 87% reduction in the cost
of care for pregnancy-induced hypertension, as well as behavioral changes amongst the team
members at the leadership, team and individual levels. This case study outlines the methods and
results of an effort to scale up efforts in improving health care in the Russian federation with
limited funding through creative solutions.
CASE PRESENTATION
In 2000, based on the success of the demonstration phase, the project proposed to continue working
for an additional two years, focusing on scale-up. The scale-up would include taking the PIH
projects from the initial three facilities to 37, five initial facilities working on NRDS to 42 facilities
and the hypertension work from five primary care facilities to 442 facilities. However the project
was faced with some challenges. Unfortunately the project was not able to secure additional
funding for scale up. This required the entire scale up plan to be reconsidered.
The leadership of this effort had difficult decisions to make during this critical planning phase and
came up with a creative solution to continuing the scale up efforts. The USAID Quality Assurance
Project (QAP) in conjunction with the Health Departments of Tula and Tver Oblasts worked
together to identify which areas of work could be covered by each group. The Health Departments
covered all in-country costs of the learning sessions, food and travel. They decided they would use
their own facilities to host learning sessions. Learning sessions were held in hospitals and other
government owned facilities. This showed a new level of commitment and ownership, which
proved to be extremely useful to achieving the results. The QAP team covered all costs for
technical assistance.
1
Administrative region.
MANAGEMENT AND OUTCOME
The health authorities of both Tula and Tver Oblasts were committed to playing the leadership role
in the scale up. It was agreed, that in order to enhance the chances of success in the scale up, it had
to be led from within the health authority, with QAP helping them in the background. The
demonstration phase had evolved champions in improvement and in the clinical topic areas. These
are staff of the health authority facilities of Tula and Tver who had played important roles in the
demonstration phase, and who became skilled in improvement and, or the clinical topic of the
improvement. In the scale up they were selected to lead several teams each. To equip them in doing
so, they were given training in adult training techniques, team facilitation and coaching as well as
improvement methods and the clinical topic areas.
During scale up, the facilities in each oblast were grouped into clusters which were called interregional centers. These were virtual centers but represented a grouping which was led by two
champions from the original facilities, one in improvement and another in the topic, and who
worked together on the improvement. These groupings were re-organized three times in the course
of the work, a part of iteratively adjusting and improving the design of the scale up phase.
The scale-up was organized as a series of steps, with specific activities happening at each of them
and clear roles and responsibilities for the teams and the champions. It was decided that the teams
will report on progress to the monthly meeting of the health authority. The champions were
mentored throughout the scale up. Notably, the scale up required less site visits from the USA than
the demonstration phase. The teams received their facilitation and mentorship primarily from the
Tula and Tver champions and from the Chief of the Methodological Center for Quality at the
CPHRI in Moscow.
Discussion
Although there was a lack of funding to scale-up, the work did not suffer. The methods used were
essentially those for the demonstration phase combined with ideas from the Diffusion of
Innovationsi, specifically the idea of “homophily”, which Everett M. Rogers describes as the
interaction of people with similar backgrounds learning from one another. If there had been more
funding available in the scale up, this scale up approach would not have been applied and perhaps
country ownership and commitment would not have been at the same level. Due to the ownership
exhibited by the Russian Federation the improvement efforts that originated in Tula and Tver
Oblasts have continued and expanded further. Surprisingly, the results were better in the scale up
phase, which are believed to have occurred for two reasons. First, QAP and the Russian Federation
learned from the critical demonstration phase. They then applied that learning to the facilities
included in the scale up phase and adapted as necessary. A second reason for success was the
utilization of champions from the demonstration phase to pass on their learnings and techniques
during learning sessions. This provided understanding and motivation through the scale up, leading
to outstanding and most importantly sustainable results. The results can be seen below in the two
graphs, which show percent of neonates with respiratory distress (RD) who died during the first
week of life in the demonstration phase and scale up phase, respectively, in Tver Oblast.
35.0
29.2
30.0
25.0
20.0
20.0
18.2 18.2
16.0
10.0
16.7
15.6
12.5
15.0
14.8 14.3
12.5
9.5
10.7
13.3
5.0 4.3
0.0
10.0
5.7
7.4
4.5
3.6
4.5
5.1
3.3
3.1 3.4 2.8
0.0
9.1
8.9
6.9
6.3
4.0
5.6
Infant Mortality, Neonatal Mortality, Early Neonatal Mortality
all Tver Oblast during the Scale up Phase, 1998-2003
Early Neonatal Mortality
Neonatal Mortality
Infant Mortality
25
DEATHS PER 1,000
Percentage of neonates with RD who died in first week of
life
Percent of neonates with RD who died in the first week of life during the
Demonstration Phase. Five hospitals, Tver Oblast.
20
19.5
17.6
17
16.4
15
14.80
13.4
10
10.3
13.9
11.1
9.6
7.9
8.8
7.40
6.5
5
8.90
5
6.00
4.80
0
1998
1999
2000
2001
2002
2003
7.7
5.4
Questions
1. If funding is a constraint during a scale-up project, discuss the creative solutions that can
be taken to continue spreading improvement efforts. (600 words
i
Everett M. Rogers. Diffusion of Innovations 5th Edition. Free Press 2003.