Better health processes and outcomes in Low-Income ... Reorganization of call schedule to ensure skilled provider at majority of births Reorganization of patient flow to include separate

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Better health processes and outcomes in Low-Income

Countries: How do we get there?

A. Maina Boucar, MD, MPH

USAID – Applying Science to Strengthen and Improve Systems

Regional Office for Francophone Africa

Niamey – Niger

USAID Applying Science to Strengthen and Improve Systems2

In Niger…

• A woman dies every 2 hours of pregnancy/ childbirth

complications

• A woman faces a one in seven chance of dying from

pregnancy-related complications during her lifetime

• Maternal Mortality Ratio: 620/100,000 (DHS 2012)

• Post-partum hemorrhage is the single largest cause of

maternal mortality in Niger (29%)

• BP linked conditions are the 3rd cause of maternal

mortality

• 40 % of children suffer from chronic malnutrition

• 50% of early childhood deaths associated with malnutrition

WHY?


Why do we fail to address these issues?

Evidence base high impact

interventions (examples)

PEE screening and case

management

Infection Prevention

AMSTL, ENC

Blood management


Hausa Proverb

“The world is like

a pregnant

woman;

you never know

what will

emerge.”

USAID Applying Science to Strengthen and Improve Systems

Opportunities and challenges

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• Post-partum hemorrhage is the single largest cause of

maternal mortality in Niger

• Active management of third stage of labor (AMTSL) reduces PPH by over 50% when correctly implemented;

• The challenges for us were:

How to move research into practice--at scale--in the resource-poor settings where most women die of PPH?

How to strengthen health systems to implement high impact interventions at scale?


USAID-Health Care Improvement Project Niger

USAID-HCI assisted MOH in 48 MOH sites in 7 of 8

regions

Maternal Newborn Care:

AMTSL/Essential Newborn Care:

• 33 MOH sites; 64% districts; 31,085 births in 2008

Pre-eclampsia/Eclampsia:

• 31 MOH sites; 119,045 patient contacts/year

Child Health:

IMCI and Malnutrition

• 15 MOH sites

FY08 Budget: $800,000; 4 staff


Site QI Team



Participants to a Provincial Learning

Session


Program Impact: NigerReduction in Post-partum Hemorrhage

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Examples of Changes

AMTSL stamp

Cooler for Ocytocine

Infection

Prevention

Materials

Delivery privacy areas

AMSTL

Reorganization of call schedule to ensure skilled provider at majority of births

Reorganization of patient flow to include separate triage, labor, and delivery areas

Daily review/feedback on completed partograms by senior midwife


Rewards to best QITs during LS


A National Learning Session


19%

95% 90%94%94%

0%

1%

2%

3%

4%

5%

0%

20%

40%

60%

80%

100%

J A J O J A J O J A J O J A J O J A J A

Pe

rc

en

tag

e o

f P

os

t P

artu

m H

em

orrh

ag

es

de

tec

ted

Pe

rc

en

tag

e

Observation: % adherence to AMTSL norms

Simulation: % adherence to AMTSL norms

Record review: % adherence to AMTSL norms

Record review: % deliveries with 3 key AMTSL components

Record review: % facility deliveries with Post Partum Hemorrhage

2006 20082007

Start of collaborative End of collaborative

2009 2010

Sustaining gains for active management of the third stage of labor (AMTSL) in 20 sites in Niger


Scaling up EONC best practices fromNiger to Mali

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Niger

Mali


Wave 1 (Oct 2009) ~ 1066 births per month in 41 facilities (2 districts) Wave 2 (Oct 2011) ~267 births per month in 21

facilities Wave 3 (Oct 2012) ~1100 births per month in 83 facilities (3 new districts)

Mali: Preventing post-partum hemorrhage in Kayes Region

0

10

20

30

40

50

60

70

80

90

100

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Pe

rce

nta

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of

bir

ths

re

ce

ivin

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MT

SL

Po

st-

pa

rtu

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em

orr

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Percentage compliance with AMTSL norms and post partum hemorrhage rate. Comparison of wave 1, 2 and 3 sites in 145 health

facilities in 5 districts of MaliWave 1 sites PPH Wave 3 sites PPH Wave 1 sites AMTSL

Wave 3 sites AMTSL Wave 2 sites AMTSL Wave 2 sites PPH


Jan 10: Baseline results restitution and orientation in

QI and collaborative

May 10: Coaching visits

Nov 10: LS2 (per district) + key changes sharing

Apr 11: LS3

Jun 11: Coaching visits

Nov 09: Baseline Assessment

Feb-Mar 10: Providers’ training in AMTSL/ENC

and QINiger EONC Collaborative

Experience sharing

Apr 10: Training of coaches; LS1 + Key successful

changes sharing on Niger

Jul 10: Coaching Visits

Feb 11: Coaching visits

Mar 11: Coaches’ meeting

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

0.0

1.0

2.0

3.0

4.0

5.0

9-Oct

N D J10 F M A M J J A S O N D J11 F M A M J J A S O N D

% B

irth

s c

ov

ere

d b

y A

MT

SL

po

st p

art

um

he

mo

rrh

ag

e r

ate

% post partum hemorrhage % births covered by AMTSL

Average # monthly births: 1,024

AMTSL coverage and post-partum hemorrhage rates in 41 target facilities,

Kayes & Diema Districts, Mali, Oct. 2009 – Dec. 2011

Mali: AMTSL & post-partum hemorrhage management

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The Science of Improvement

A structured approach to deliver

evidence based high impact

interventions at scale


Different Ways by Which Quality Can Become Better

• Through accumulation of knowledge and

experience over time

• Through trial and error

• Through advances in science and scientific

experiments

• By coincidence

• On the basis of improvement science


The Framework for Health Care Quality Improvement

Associates in Process Improvement21


Principles of Improvement

• “Fundamental Concept of Improvement:

“Every System is perfectly designed to achieve exactly the results it achieves”

• Principles of Improvement:

– Understanding work in terms of processes and systems

– Implementing high impact interventions by redesigning processes

– Process redesign by teams of front-line health care providers supported by

District and Regional Health Management Teams

– Focusing on patient needs and preferences in the redesign of processes

– Testing changes to see if they yield improvement

– Data management by teams of health care providers for continuous

improvement

– Shared Learning facilitated process by which multiple teams learning from

each other

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Employee Engagement(…or lack thereof)

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Chetima Boucar, MD, MPH but also

Head of his traditional Community

Documents

Better health processes and outcomes in Low-Income ... Reorganization of call schedule to ensure skilled provider at majority of births Reorganization of patient flow to include separate