Background
Access to health services in Afghanistan has expanded in the last decade; however, gaps in care quality and outcomes of care remain a challenge. Recognizing these gaps, in 2009 the USAID Health Care Improvement Project (HCI) began assisting the Ministry of Public Health (MoPH) in Afghanistan to improve the quality of health services. Though eventually scaled up to nine provinces, in 2009 the MoPH and HCI began developing and testing a facility-based, scalable model of maternal and newborn interventions in health facilities in Kunduz and Balkh provinces and in several large public and private hospitals in Kabul.

Case description
To address these issues, the MoPH and HCI applied the collaborative improvement approach, which links the efforts of multiple teams focused on making improvements in the same area of care to achieve the same aims. As demonstration sites, two provincial level quality improvement teams (QITs) were established in Kunduz and Balkh provinces that, in turn, supported 25 facility-level QITs chosen by purposive sampling. In addition, three government maternity hospitals and three private hospitals in Kabul were selected by the MoPH to participate in a demonstration hospital collaborative. Measurable gains were achieved in these demonstration sites for use of the partograph, compliance with antenatal care counseling, vaginal births for which all three elements of active management of the third stage of labor were performed, and compliance with newborn and postnatal care standards.

Discussion and evaluation
Quality of care can be significantly improved by engaging teams of frontline workers to identify problems and find local solutions for those problems. Based on the results achieved in Kunduz, Balkh, and Kabul, the collaborative improvement work was expanded from 2010–2012 to seven more provinces. The results achieved on the ground also led the MoPH to establish a unit for quality and a national health care quality improvement strategy for Afghanistan.

Conclusions
Afghanistan demonstrates that even in fragile states, measurable improvements in actual patient care at the frontlines of service delivery can be achieved while systematically building capacity at all levels of the health system through national leadership and policy making.