Quality Talks

In Nigeria’s Delta State, a public/private partnership is rehabilitating 25 defunct health facilities to provide quality primary health care services to remote and underserved communities. The Primary Health Care Revitalization and Access to Finance Scheme hands over public health facilities to private providers and outsources primary health care services to these providers.

Dr. Ibironke Dada, Director for quality activities, MNCH projects at the Pharmacess Foundation, tells us how the scheme combines innovative financing, enrollment in a public health insurance scheme and a quality improvement plan to increase both access to health care and the quality of the services provided.

A recent study conducted in Nepal assessed the indirect impact of the COVID-19 lockdown on the quality of intrapartum care that women received in health facilities. The study, published in The Lancet, looks at the implications of a reduced access to care, but also at the gaps in the quality of the care provided.

Dr. Ashish K.C, who led the study, is a perinatal epidemiologist and a researcher specializing in quality of care, based in the Department of Women's and Children's Health, University of Uppsala, Sweden. He tells us about the study's findings, their implications during the COVID-19 lockdown, and how health workers have developed solutions to provide quality intrapartum care even under extraordinary circumstances.

Many children’s deaths could be prevented if the most sick children were identified soon after their arrival in a health facility, and were prioritized to be treated immediately.

The Emergency Triage Assessment and Treatment (ETAT) programme was ​initially designed by the World Health Organization in 2005 to drastically reduce waiting time, improve flow and access to quality protocol-driven care for children presenting to hospitals in resource-limited settings, and thereby improve pediatric care and outcomes. Many countries have since adapted it for implementation in their context; in Sierra Leone, it is implemented as ETAT+.

ETAT+ whole systems approach has become an integral component of Sierra Leone’s efforts to improve the quality of pediatric care.  In district hospitals implementing the programme, the proportion of children who died after arrival in hospital dropped by nearly 40%. The programme’s lessons are now being applied to other areas of care, with a similar initiative being implemented for obstetric care (obstetric ETAT).

In this episode, Dr. James Bunn, Child Health Specialist at the World Health Organization in Sierra Leone explains the changes that ETAT+ has brought about through improving patient flow, task shifting, and responding to bottlenecks which delay treatment. This has been implemented through new on-the job training methods including mentoring. He describes how improving quality of care can be possible even in facilities with scarce resources.

A recent study conducted in Ghana, Guinea, Myanmar and Nigeria and published in the Lancet showed that one in three women experienced physical or verbal mistreatment during childbirth in health facilities.

Adrienne Strong is a medical anthropologist and Assistant Professor of Anthropology at the University of Florida who studies maternal mortality and women's health in Tanzania, and the notions of ideal comfort, care, and support for pregnant women in labour.

She observed a birth companionship programme run by an NGO in maternity wards in the Kigoma region of Tanzania in 2018. She explains how the programme designed to improve both the women’s experience of care and clinical outcomes failed to reduce  the disrespect and abuse directed at the patients. In fact, in some cases, the birth companions themselves justified the mistreatment or took part in it, targeting the very women they were meant to support.

For more on respectful maternal care from Adrienne Strong, check out her new book: Documenting Death: Maternal Mortality and the Ethics of Care in Tanzania. Strong, A. 2020;Berkeley, CA: University of California Pres, which will be available in the Spring of 2020 at this address https://www.ucpress.edu/discipline/antmaj/anthropology

Chhavi Sharma, a medical student at the Lady Hardinge Medical College in New Delhi, explains how learning Quality Improvement skills, in addition to her clinical skills, is changing the way she approaches patients, and preparing her to be a better medical professional.

Chhavi is a founding member of  Be the Change,  a group of medical and nursing students committed to improving quality of care and supported by India’s Nationwide Quality of Care Network.

Emmanuel Ayire Adongo, from the World Health Organisation Country Office in Ghana explains how a simple tool – a scorecard, building on an existing policy and community engagement structures – has made it possible to engage communities in the planning, roll-out and assessment of health services. From community representatives touring facilities, to community members pitching in to improve the infrastructure, listen to the impact this tool had on the involvement of the community, the accountability of the health system, and, ultimately, the quality of care.

The Policy, Planning, Monitoring and Evaluation Division (PPME) of the Ghana Health Service is now planning to expand the roll-out of the scorecard country wide.

Over 90 health facilities in the Eboni and Kogi states of Nigeria have joined a quality improvement initiative to improve the quality of care for women and newborn on the day of birth.In just two years, they have seen massive improvement in some of the key clinical practices such as managing post-partum haemorrhage, resuscitating a newborn or encouraging early breastfeeding. And the communities they are serving are seeing a difference in the care they receive.

Dr Ugo Okoli is the Deputy Chief of Party of the Maternal and Newborn Child Survival Programme (MCSP) in Nigeria, leading the quality improvement work in reproductive, maternal and newborn health in Ebonyi and Kogi States. She explains what are the success factors of this initiative, and some of the pitfalls to watch out for.

There has been several pieces of work published recently on how health systems are failing and how they have to evolve and focus on quality of care, to adapt to changing needs and support Universal Health Coverage (UHC).

Last month, The Lancet Global Health Commission on High Quality Health Systems in the SDG Era published its report examining what a high-quality health system should look like. A study by the National Academies of Sciences, Engineering, and Medicine looks into the global impacts of poor-quality health care and recommends ways to improve quality while expanding UHC. And a joint report by the World Health Organization (WHO), Organisation for Economic Co-operation and Development (OECD), and the World Bank Group details the economic and social costs of poor quality of care.

These publications look at the health system perspective. But Nigel Livesley, who works for the Network for Improving Quality of Care for Maternal, Newborn and Child Health suggests that to drive these system changes, we need to look at how things are done in health facilities and how quality of care can be and is improved there.

Here is why.

What can anxious parents of small and sick newborns do to care for their baby, in a health facility? And how does their willingness to help go down with health workers? Professor Arti Maria, Head of Neonatology at the Ram Manohar Lohia Hospital, in New Delhi, India has, for over a decade, been pioneering a family participatory care approach, to involve parents and relatives in caring for sick and small newborns. She tells us about the challenges, the impact on the experience of care, and how this approach has changed the power balance between providers and beneficiaries of care.

 

Health facilities need to have access to water, sanitation, energy, as well as supplies of medicines and equipment to deliver quality care to women and newborns. These pre-requisites are a part of the World Health Organization’s standards for improving quality of maternal and newborn health in health facilities.

Natasha Mwenda, Manager of the Deliver Life project in Malawi, which is run by WaterAid and supported by the UK’s Department of International Development (DfID), explains how increased access to water, sanitation and hygiene impacts quality of care for mothers and newborns.

For more on the Quality of Care Network: www.qualityofcarenetwork.org