Landscape Analysis Initiatives for Quality Improvement of Intrapartum Care

Goals & Objectives

• Map intrapartum quality and Quality

Improvement (QI) initiatives in Kenya, Uganda and Uttar Pradesh (UP)

Identify successes constraints, challenges and opportunities both in terms of QI activities and partnerships

Scope of work

Target Area

Health service delivery

Pre conception care

Antenatal Intrapartum care Hospital and clinical level

Referral

Health workforce

Health information systems

Postnatal care

Follow up

Child care

Access to essential medicines

Health systems financing

Leadership and governance

QI Framework

5 Domains

40 Attributes

• Alignment

• Attention to patients needs (PCC)

• Achievability

• Sustainability

• Cost and value for Money

Key elements that need to be found in a domain

e.g.

• Staff capacity

• Privacy

• Leadership

• Improved budgeting and forecasting

• Affordability for facilities

6 Scores

Dimensions and factors related to QI included in the projects identified Kenya

Key Findings

Progress of QI

Timeframe

Policy framework

Coordination of initiatives & Gov engagement Country

Kenya

Uganda

2001 2008 relaunch

National strategy (2011) Modalities for implementation (2017)

2005 (HIV focus) 2010 more broadly

Health Sector QI Framework & Strategic Plan 2015/16 –2019/2020

Govt .QI coordination Structure

Good IP engagement

Govt .QI coordination Structure

Good IP engagement

2012 (QoC projects) 2014 (Govt)

Nat.QA 2014 onward Dakshata & Q+ approved 2016

QOC through accreditation

Health Partners Forum recently set up

Key QI Projects Kenya

• Kenya Quality Model for Health (KQMH) through the Department of Standards, Regulation & Accreditation, GoK

• AFYA JIJINI through IMA Health

• Jacaranda Maternity (and other public facilities) through Jacaranda Health

• Health Sector Programme (HSP) through GIZ, Evaplan and IHPMR

• Maternal and Child Survival Programme (MCSP) through JHPIEGO

• ASSIST through URC in support of AIDS, Population and Health IntegratedAssistance SupportingAPHIA Plus programme partners.

• MNH Project through UNICEF

• Making it Happen through LSTM

• Maternal and Newborn Health Improvement Project (MANI) through OPTIONS

• Community-Facility-linked Continuous Quality Improvement through Pathfinder

• Pre term Birth Initiative through UCSF and University of Nairobi

• AQCESS Project throughAKU

Key QI Projects Uganda

• Health Sector Quality Improvement Framework and Strategic Plan (QIF&SP) GoU.

• Applying Science to Strengthen and Improve Systems (ASSIST) URC

• Saving Mothers Giving Life (SMGL) multiple partners including URC

• Health Service Improvement for Health Facilities (HSIHF) supported by JICA

• Support to PNFP facilities & Institutional Capacity Building Project (ICB&PNFP) supported by BTC

• Saving Newborn Lives (SNL) implemented by Save the Children

• Fistula Care Plus project (FCP) implemented by Engender Health

• Preterm Birth Initiative (PTBi) supported by the B&MGF

Key QI Projects UP

• Better Birth throughAriadne Labs and Population Services International

• Technical Support Unit set up by University of Manitoba and India HealthAction Trust (iHAT) with communication support from Global Health Strategies.

• Facility Based Newborn Care initiative through UNICEF.

• FOGSI assisted private facility support through Jhpiego.

• Merry-gold Health Network launched by Hindustan Latex Family Planning Promotion Trust (HLFPPT).

• National Quality Assurance Program supported by KayakalpAward Scheme implementation by National Health Mission-Uttar Pradesh.

• Uttar Pradesh Health Systems Strengthening Project (UPHSSP) supported by World Bank.

Key Players

Estimated trends in funding for the QI initiatives identified

Kenya Uganda India (UP)

Geographic Coverage

Implementing Partners

NGOS

Government al Bodies

Different categories of design and implementing partners identified

UN Agencies

Donors

Foundations and Private Entities

Academic Institutions

Common Features

Extremely diverse & fragmented

Few exclusively IPC

Externally funded / limited level of local ownership

Strongest area - achievability

Weakest areas - sustainability and patient centred care (PCC).

Limited demonstrable impact on Maternal / Newborn Morb & Mort.

What the study tells us

Lessons learnt

QI/QoC on the national & global agenda

QI approach more common in Kenya & Uganda / few projects exclusively IPC

Donors are driving the process

Limited investment and engagement from national counterparts • A few good practices, some encouraging results but little traction on health systems and not replicable at scale

• Limited reach for comprehensive quality and respectful care

We have seen very good things

We have also seen obvious shortcomings in facilities where QI is implemented

Three main gaps

QI programmes tend to be ‘vertical’ and address only some of the determinants of quality childbirth services

Insufficient attention paid at the needs & preferences of patients

Lack of engagement & investment for national counterparts

Projects identified address some QI attributes only

QI makes up an essential element of a fully functional health system

Functional referral system

Supportive supervision

Management capacity

Skilled health providers

Cleanliness & infection prevention

Record keeping/ reporting

Equipment

QOC/QI

Patientcentred care

Drugs and supplies

Infrastructure

Leadership

Community Mobilisation

Less attention to the domain of Patient Centered Care

The level of ownership and support from national counterparts tends to be limited

This was apparent in the 3 countries

Precludes sustainability and scalability

General lack of leadership at national, district and county levels

Results in insufficient human and financial resources which impact the capacity of the local/national counterpart to effectively engage

Policy recommendations

Integrate QI activities within broader MNH Programs

Clinical interventions

System strengthening interventions

QI interventions

Capacity building in BEmOC and CEmOC, PPH, prevention & management of maternal infection, etc

HR development, procurement and supply chain, referrals, etc.

QIT, mentoring, support to specific QI plans, etc.

Focus on changing attitudes through a PCC approach

Listen to patients and their families and take into account their specific needs

Create and maintain favouring environments for the provision of quality MNH services

Involve communities in the monitoring and management of progress

Foster Engagement – Support Decision making cycle

Engagement Task Force

Cost Benefit Analysis

• VFM of doing QI vs not doing it

Drive Policy

• Mentor relevant Governmental departments, local authorities & facilities

• Coordinate and capitalise QI initiatives

• Link QI initiatives with functional health systems

Generate Evidence

Capacity Building Workshops for IPs

• Advocate for measuring the impact of the initiatives

• Provide tools & methods for evaluating MNH outcomes

• Collectively demonstrate results.

Support & Practice Monitor &

Evaluate outcomes

• Consider Road Map approach to engage Govt in QI ownership.

Regional Resource Center

• Disseminate good practices

• Provide TA in QI related areas upon request

• Disperse seed money to complete/improve QI interventions

• Link global, regional and local QI initiatives