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Factors influencing implementation of integrated management of childhood illness in Lindi Region, Southern Tanzania.
Tanzania Journal of Health Research. 2018 Jan; 20(1): p.Background: Save the Children Tanzania has been supporting several projects in Lindi Region including implementation of health facility based Integrated Management of Childhood Illness (IMCI) services in Kilwa, Ruangwa and Lindi rural districts. The objective of this study was to assess the IMCI services in a sample of health facilities and explore factors affecting the service provision and sustainability in Lindi, Tanzania. Methods: A cross-sectional study was conducted involving 27 health facilities. Quantitative and qualitative approaches were used to collect the required data. Focus group discussions and in-depth interviews were also used to evaluate the IMCI services in these facilities. Results: All health facilities visited were found to have adequate supply of IMCI equipment. However, there was inadequate availability and distribution of clinical officers in the districts. None of the 41 clinical officers observed, assessed sick children for all items in the IMCI checklist. Furthermore, health centres and dispensaries were found to have a serious shortage of essential medicines. Oral antibiotics for bacterial infections were available across health facilities. Amoxicillin was found in 4(44%) health centres and 7 (46.7%) dispensaries; Ampicillin was only available at 4(44.4%) health centres and 1 (6.7%) dispensary. Considerable challenges in access to health services were identified and they included long distances to health facilities, inadequate and unaffordable transport systems and continuous limited quality of care due to shortages of trained staff and drug stock outs. In addition, caregivers were found to have limited awareness of danger signs and symptoms of childhood illnesses. Conclusions: The implementation of IMCI services in the three districts of Lindi region experiences multiple challenges despite the availability of adequate infrastructure for program implementation. This calls for strengthened supportive supervision, constant provision of medical supplies and training of IMCI health workers to improve services delivery to sick children. In addition community level promotion of prompt modern health care seeking behaviour is essential to enhance childhood illness care and treatment.
Archives De Pediatrie. 2018 Feb; 25(2):73-74.Add to my documents.
Stigma management intervention to improve antiretroviral therapy adherence: Phase-I test of concept trial, Cape Town South Africa.
Global Public Health. 2018 Nov 30; 16 p.Combination antiretroviral therapy (cART) has transformed HIV infection from a universally fatal disease to a medically manageable chronic illness. We conducted a Phase-I test of concept intervention trial to examine feasibility and potential efficacy of behavioural self-regulation counselling designed to improve care retention and cART adherence. The intervention was culturally adapted from client-centered evidence-based interventions that are grounded in behavioural self-regulation theory and available in the US. The intervention adaptation included enhancements to directly address HIV stigma and alcohol-related sources of nonadherence. Fifty patients receiving cART in Cape Town, South Africa were randomised to receive either: (a) five weekly cellphone-delivered sessions of stigma and alcohol-enhanced behavioural self-regulation counselling or (b) a contact matched control condition. Participants were baseline assessed and followed for two weeks post-intervention, with 94% of participants retained throughout the study. Participants receiving the intervention significantly improved cART adherence from baseline-to-follow up and improvement was significantly greater than the control condition. Behaviours related to stigma and alcohol use that impede cART adherence were significantly reduced, and there was uptake of adherence improvement strategies. The current study supports the potential efficacy of relatively brief behavioural self-regulation counselling delivered by cellphone in a context of differentiated care in South Africa.
Use of an Evidence-Based Guideline for Management of Side Effects from Long-Acting Reversible Contraceptives: A Quality Improvement Report.
Journal of Midwifery and Women's Health. 2018 Nov 16;INTRODUCTION: Many health care providers believe that women who initiate long-acting reversible contraceptives (LARC) discontinue the method because of side effects too soon for the method to be economical. The purpose of this quality improvement project was to implement and evaluate an evidence-based telephone triage nursing guideline for management of side effects of LARC with an ultimate goal of reducing the number of early discontinuations. PROCESS: A telephone triage guideline was adapted from the Contraceptive Choice Project's Clinician Call Back System, supplemented with evidence-based resources, and approved by clinicians at 2 community women's health and midwifery offices. Baseline retrospective data were collected on all women over the age of 18 who had LARC inserted at the 2 sites in the year prior to guideline implementation and in the 3 months after implementation. Rates of LARC removal at or before 3 months postinsertion, before and after guideline implementation, were evaluated. OUTCOMES: Approximately 1 in 5 women called for help managing LARC side effects. Of the callers, 3 of 32 (9.4%) women receiving standard care discontinued their LARC prior to 3 months, whereas 0 of 24 women who were triaged using the guideline discontinued their LARC prior to 3 months (P = .12). Cramping, bleeding, and malposition or expulsion were the most common concerns and reasons for discontinuation. DISCUSSION: Fewer women than anticipated called to report side effects, and even fewer chose to discontinue their LARC early. There were fewer discontinuations with guideline use, but this was not a statistically significant difference. Most women did not discontinue their LARC early for any reason, including side effects. (c) 2018 by the American College of Nurse-Midwives.
Mapping the extent to which performance-based financing (PBF) programs reflect quality, informed choice and voluntarism and implications for family planning services A review of indicators.
Washington, D.C., Population Council, The Evidence Project, 2018 Sep. 23 p. (Research Report)Results-based financing (RBF) initiatives, which operate within the much larger financial and programming contexts of health systems, aim to expand coverage, improve quality and reduce consumer financial obligations at the country level in line with a nation’s decision to progress toward universal health coverage. RBF programs have the potential to ensure that clients’ needs for quality services are met through use of strategic incentives in health care provision and promoting more client-centered healthcare systems. Performance-based financing (PBF) programs are considered a specific subset of RBF initiatives and are distinguished by a focus on monetary incentives to healthcare providers for achieving agreed performance measure under certain conditions. While both PBF, which uses financial disbursements to incentivize health service delivery and quality, and rights-based programming have informed at different times efforts to strengthen and scale FP services, there is has been little done to understand the linkages between PBF and a rights-based approach (RBA) to FP services. To address this gap, a review of PBF operations manuals was undertaken together with an analysis of PBF indicators relevant to FP services. This paper presents the results of the analysis of PBF indicators from country-sourced operational documents to determine the extent to which FP indicators are sensitive to the principles associated with an RBA. The review catalogued FP indicators used in PBF programs and assessed their sensitivity to the rights principles. The relevant indicators were sources through 23 operational documents and 18 quality checks. We found 452 FP-related indicators, 57 were for quantity-based performance indicators and 395 questions were used to assess the quality of FP services. The majority of quantity-based performance indicators related to contraceptive service utilization. Fewer quantity-based indicators linked performance incentives to FP counselling, antenatal care, provision or referral by community health workers and one related to demand side incentive for FP counseling. The rights principles most often addressed are availability, quality, including privacy and confidentiality, and informed choice and acceptability and accountability were addressed to a lesser extent. There was no implicit link to the rights principles of accessibility, non-discrimination, and agency. The review shows that existing PBF indicators capture some key elements of an RBA. For instance, aspects of quality and availability are extensively measured. Adapting existing measures could help to ensure existing indicators better align with an RBA. For example, informed choice is tracked in several PBF programs now but with further adoption and adaptation of the method information index and related counseling quality indicators, it is reasonable to expect a greater alignment of PBF with rights principles. Despite the opportunity for greater integration, there are challenges inherent in measuring some dimensions of an RBA, particularly related to client-provider interactions, service users’ experience and engagement. For instance, agency and accessibility require information from the consumer perspective that is not easily observed by third parties.
Mapping the extent to which performance-based financing (PBF) programs reflect quality, informed choice, and voluntarism and implications for family planning services A review of PBF operational manuals.
Washington, D.C., Population Council, The Evidence Project, 2018 Sep. 38 p. (Research Report)Expanding access to and use of voluntary family planning (FP) services is a well-established global health goal– it is a specific target under the Sustainable Development Goal (SDG) of good health and well-being, an integral component of Every Woman Every Child (EWEC), and the overall objective of the Family Planning 2020 (FP2020) partnership, among other initiatives. One promising approach for achieving global voluntary FP goals is performance-based financing (PBF), which deploys financial incentives to the health system to improve service availability, utilization, and quality as well as addressing some public financial management bottlenecks by directly targeting resources to facilities based on performance. Setting global voluntary FP goals implies following a rights-based approach to family planning, which uses a set of standards and principles to guide program assessment, planning, implementation, monitoring, and evaluation that enables individuals and couples to decide freely and responsibly the number and spacing of their children, to have the information and services to do so, and to be treated equitably and free of discrimination. While both PBF, which uses financial disbursements to incentivize health service delivery and quality, and rights-based programming have informed efforts to strengthen and scale FP services, there are gaps in understanding the linkages between PBF and a rights-based approach (RBA) to FP services. To address this gap, a review of performance-based financing (PBF) operations manuals was undertaken together with an analysis of PBF indicators relevant to FP services. This report assesses whether existing FP indicators are sensitive to the principles associated with an RBA.
Engaging stakeholders: lessons from the use of participatory tools for improving maternal and child care health services.
Health Research Policy and Systems. 2017 Dec 28; 15(Suppl 2):106.BACKGROUND: Effective stakeholder engagement in research and implementation is important for improving the development and implementation of policies and programmes. A varied number of tools have been employed for stakeholder engagement. In this paper, we discuss two participatory methods for engaging with stakeholders - participatory social network analysis (PSNA) and participatory impact pathways analysis (PIPA). Based on our experience, we derive lessons about when and how to apply these tools. METHODS: This paper was informed by a review of project reports and documents in addition to reflection meetings with the researchers who applied the tools. These reports were synthesised and used to make thick descriptions of the applications of the methods while highlighting key lessons. RESULTS: PSNA and PIPA both allowed a deep understanding of how the system actors are interconnected and how they influence maternal health and maternal healthcare services. The findings from the PSNA provided guidance on how stakeholders of a health system are interconnected and how they can stimulate more positive interaction between the stakeholders by exposing existing gaps. The PIPA meeting enabled the participants to envision how they could expand their networks and resources by mentally thinking about the contributions that they could make to the project. The processes that were considered critical for successful application of the tools and achievement of outcomes included training of facilitators, language used during the facilitation, the number of times the tool is applied, length of the tools, pretesting of the tools, and use of quantitative and qualitative methods. CONCLUSIONS: Whereas both tools allowed the identification of stakeholders and provided a deeper understanding of the type of networks and dynamics within the network, PIPA had a higher potential for promoting collaboration between stakeholders, likely due to allowing interaction between them. Additionally, it was implemented within a participatory action research project. PIPA also allowed participatory evaluation of the project from the perspective of the community. This paper provides lessons about the use of these participatory tools.
Contraceptive Implant-Related Acute Ulnar Neuropathy: Prompt Diagnosis, Early Referral, and Management Are Key.
Eplasty. 2018; 18:e28.Objective: Subdermal contraceptive implants are a well-established method of contraception. Aside from common side effects such as irregular menstrual periods, headaches, and weight gain, rarer complications related to their insertion and removal have been reported. These include traumatic peripheral neuropathy after procedures to remove nonpalpable implants. Only 2 cases of ulnar neuropathy after insertion of a contraceptive implant have been described in the literature, one which resolved spontaneously and another in which postoperative recovery was not described. We report a case of acute ulnar nerve neuropathy in a patient postinsertion of a contraceptive implant who achieved symptom resolution after prompt referral and treatment at a specialist plastic surgery center. Methods: A 22-year-old, right-hand-dominant woman presented 1 day postinsertion of a contraceptive implant (Implanon) in her left arm with paresthesia along the ulnar distribution of her hand and forearm, as well as shooting pain on palpating the course of the ulnar nerve. Ultrasonography found the implant to be lying in the subfascial plane of the inner arm. Results: The implant was found lying in the perineurium of the ulnar nerve, causing ulnar nerve neuropathy. A review 3 months after removal of the implant showed near-complete resolution of her symptoms. Conclusions: Complications related to implantable contraceptives may lead to significant morbidity. Appropriate training for health care professionals administering the devices is essential, as well as early referral to a specialist center to prevent permanent damage.
Geneva, Switzerland, World Health Organization [WHO], 2018. 116 p.The guideline uses state-of-the-art evidence to identify effective policy options to strengthen community health worker (CHW) programme performance through their proper integration in health systems and communities. The development of this guideline followed the standardized WHO approach. This entailed a critical analysis of the available evidence, including 16 systematic reviews of the evidence, a stakeholder perception survey to assess feasibility and acceptability of the policy options under consideration, and the deliberations of a Guideline Development Group which comprised representation from policy makers and planners from Member States, experts, labour unions, professional associations and CHWs. Critical to the success of these efforts will be ensuring appropriate labour conditions and opportunities for professional development, as well as creating a health ecosystem in which workers at different levels collaborate to meet health needs. Adapted to context, the guideline is a tool that supports optimizing health policies and systems to achieve significant gains to meet the ambition of universal access to primary health care services.
Supporting community mobilizers to provide quality sexual and reproductive health care in urban Tanzania.
Watertown, Massachusetts, Pathfinder International, 2018 Oct. 12 p.Gaps in human resources for health are among the most influential factors underlying poor health systems performance. Community health workers have positively impacted health outcomes by providing health services and linking the community to the health system. While there is evidence to support capacity development and successful deployment of community health workers, evidence of effective quality assurance mechanisms is lacking. Chaguo la Maisha--a three-year, anonymously-funded project implemented by Pathfinder International in Dar es Salaam, Tanzania--aimed to create an enabling environment for women to choose whether and when to bear children. Community health workers are integral to achieving this goal. This technical brief explores the project components designed to support quality in community health worker services and to support community health workers to build service-seeking behaviors as well as mutual accountability and shared responsibility for health between the community and the facility.
International Journal of Health Governance. 2018; 23(3):226-232.Purpose: The purpose of this paper is to describe the challenges faced by health professionals in meeting Millennium Goal 5 and reducing maternal mortality in Uganda. Design/methodology/approach: Uganda is a low income land locked country with some major challenges around maternal health. There are many comprehensive and visionary plans produced by the Ugandan Government, however, there is a disconnect between policy and practice and there are many barriers to be addressed in order to reduce maternal mortality in Uganda. Findings: Despite making considerable progress in reducing maternal mortality, Millenium Development Goal (MDG) 5 was not achieved and every day 300 children and 20 mothers die in Uganda. Major barriers include lack of resources, both human and equipment, disparities in access to care, lack of clinical skills and knowledge and financial constraints. The Millennium goals are now behind us and focus has shifted to the sustainable development goals (SDGs). The Ugandan Government must focus on using these goals as part of developing the maternal and child health strategy by prioritising the human resource and health financial issues and continuing to work towards reducing maternal and perinatal mortality. Originality/value: This paper gives a succinct review of the progress of Uganda towards meeting the Millennium Goal 5 and makes key recommendations for addressing SDG 3. © 2018, Emerald Publishing Limited.
Making the leap into the next generation: A commentary on how Gavi, the Vaccine Alliance is supporting countries' supply chain transformations in 2016-2020.
Vaccine. 2017 Apr 19; 35(17):2110-2114.Add to my documents.
The effect of performance-based financing on maternal healthcare use in Burundi: a two-wave pooled cross-sectional analysis.
Global Health Action. 2017; 10(1):1327241.BACKGROUND: Several developing countries, especially in Africa, have implemented performance-based financing (PBF) schemes with the aim of improving healthcare provision. PBF was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. OBJECTIVE: To enrich existing studies on Burundi in three ways. Firstly, by evaluating the effect of PBF on maternal care at primary and hospital levels; secondly, on the possession of maternity logbooks for maternal care records; and thirdly, how the amount of subsidies influences healthcare outputs. DESIGN: We used data from repeated cross-sectional surveys in 500 households (intervention group: 225; control group: 275) conducted in 2006 and 2008. A total of 274 women, aged 15-49, who had recently given birth, were interviewed about the use of maternal healthcare and the possession of maternity logbooks. We performed a difference-in-differences analysis using pooled cross-sectional survey data from 2006 and 2008. RESULTS: We found that PBF is associated with an increased institutional deliveries probability of 39.5 percentage points (p < 0.01) - a relative improvement of 81.8%. Institutional deliveries probability increased significantly only at health centre level by 33.6 percentage points (p < 0.01), a relative rise of 80.6%. There is an indication of a positive spillover effect of PBF on the possession of maternity logbooks. We found no PBF effect on the number of antenatal care visits and anti-tetanus immunization. CONCLUSIONS: Our findings suggest that institutional delivery highly improved because it came from a low baseline and its unit payment was relatively high, leading health workers to promote its use. The fact that deliveries mainly increased in health centres and not in hospitals may be explained by the context of how health delivery is organized in Burundi. Health policymakers have to determine the appropriate financial incentives that best influence the improvement of each health service.
Factors affecting implementation of integrated community case management of childhood illnesses in South West Shoa Zone, Central Ethiopia.
Journal of Public Health and Epidemiology. 2018 May; 10(5):132-138.Ethiopia, this proven strategy is being implemented in selected districts of the regions but there are no sufficient evidences to decision-makers for improvement interventions. Cross-sectional study was conducted by including all functional health posts and HEWs from four randomly selected districts. Pre-tested structured questionnaires and observation checklist were used to collect data. Data was entered into Epi data version.3.1 and transported to SPSS v.21.0 for analysis. Bivariate and multiple binary logistic regression analysis were used to identify the determinants. 60 (60.6%) of the Health post were in good implementation category. 24 (15.3%) had only one HEW each, 26.8% had recommended three HEWs and 16 (16.2%) had no. HEWs mentored quarterly had three times better implementation (AOR) 3.14, 95% CI [1.65-6.52]). The services were less likely implemented in kebelles lacking any CHAs (AOR 0.47, 95% CI [0.19-0.83]). Health posts which were serving community for greater than eight hours per day had five times better implementation (AOR 5.33, 95% CI [2.58-9.33]). The study revealed that there is still a long way to go for better implementation of the program. Improving the program implementation needs a coordinated effort of all stakeholders at different levels. Nationally, preparing a system-wide approach towards resolving multifaceted challenges facing the programs will help attain the sectorial mission of reducing child mortality.
Effect of support supervision on maternal and newborn health services and practices in Rural Eastern Uganda.
Global Health Action. 2017 Aug; 10(sup4):1345496.BACKGROUND: Support supervision is one of the strategies used to check the quality of services provided at health facilities. From 2013 to 2015, Makerere University School of Public Health strengthened support supervision in the district of Kibuku, Kamuli and Pallisa in Eastern Uganda to improve the quality of maternal and newborn services. OBJECTIVE: This article assesses quality improvements in maternal and newborn care services and practices during this period. METHODS: District management teams were trained for two days on how to conduct the supportive supervision. Teams were then allocated particular facilities, which they consistently visited every quarter. During each visit, teams scored the performance of each facility based on checklists; feedback and corrective actions were implemented. Support supervision focused on maternal health services, newborn care services, human resources, laboratory services, availability of Information, education and communication materials and infrastructure. Support supervision reports and checklists from a total of 28 health facilities, each with at least three support supervision visits, were analyzed for this study and 20 key-informant interviews conducted. RESULTS: There was noticeable improvement in maternal and newborn services. For instance, across the first, second and third quarters, availability of parenteral oxytocin increased from 57% to 75% and then to 82%. Removal of retained products increased from 14% to 50% to 54%, respectively. There was perceived improvement in the use of standards and guidelines for emergency obstetric care and quality of care provided. Qualitatively, three themes were identified that promote the success of supportive supervision: changes in the support supervision style, changes in the adherence to clinical standards and guidelines, and multi-stakeholder engagement. CONCLUSION: Support supervision helped district health managers to identify and address maternal and newborn service-delivery gaps. However, issues beyond the jurisdiction of district health managers and facility managers may require additional interventions beyond supportive supervision.
Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda.
Global Health Action. 2017 Aug; 10(sup4):1345495.BACKGROUND: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation. OBJECTIVES: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy. METHODS: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences. RESULTS: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (>/= 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles. CONCLUSIONS: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.
Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine.
BMJ Open. 2018 Mar 22; 8(3):e019568.OBJECTIVES: To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention's impact on use and quality indicators of maternal services after 2 years' experience. DESIGN: A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention. SETTING: All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion. PRIMARY AND SECONDARY OUTCOMES: Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models. RESULTS: 14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78-4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96) CONCLUSION: The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care. TRIAL REGISTRATION NUMBER: NCT03145571; Results. (c) Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Chapel Hill, North Carolina, University of North Carolina, MEASURE Evaluation, 2018 Aug. 4 p. (USAID Cooperative Agreement AID-OAA-L-14-00004)The Partnership for HIV-Free Survival (PHFS) was a six-country initiative implemented between 2012–2016. It was designed to reduce mother-to-child transmission of HIV and increase child survival. This document focuses on seven components of PHFS in Mozambique highlighted by a legacy evaluation of partnership activities. The findings are based largely on a rapid assessment conducted by MEASURE Evaluation in Mozambique in January 2018. The core components follow: 1) Harmonized quality improvement; 2) Patient records; 3) Mother-baby pairs; 4) Breastfeeding practices; 5) Integration of services; 6) Community-patient links; and 7) Coaching.
Performance-Based Financing Empowers Health Workers Delivering Prevention of Vertical Transmission of HIV Services and Decreases Desire to Leave in Mozambique.
International Journal of Health Policy and Management. 2018 Jan 1; 7(7):630-644.BACKGROUND: Despite increased access to treatment and reduced incidence, vertical transmission of HIV continues to pose a risk to maternal and child health in sub-Saharan Africa. Performance-based financing (PBF) directed at healthcare providers has shown potential to improve quantity and quality of maternal and child health services. However, the ways in which these PBF initiatives lead to improved service delivery are still under investigation. METHODS: Therefore, we implemented a longitudinal-controlled proof-of-concept PBF intervention at health facilities and with community-based associations focused on preventing vertical transmission of HIV (PVT) in rural Mozambique. We hypothesized that PBF would increase worker motivation and other aspects of the workplace environment in order to achieve service delivery goals. In this paper, we present two objectives from the PBF intervention with public health facilities (n=6): first, we describe the implementation of the PBF intervention and second, we assess the impact of the PBF on health worker motivation, key factors in the workplace environment, health worker satisfaction, and thoughts of leaving. Implementation (objective 1) was evaluated through quantitative service delivery data and multiple forms of qualitative data (eg, quarterly meetings, participant observation (n=120), exit interviews (n=11)). The impact of PBF on intermediary constructs (objective 2) was evaluated using these qualitative data and quantitative surveys of health workers (n=83) at intervention baseline, midline, and endline. RESULTS: We found that implementation was challenged by administrative barriers, delayed disbursement of incentives, and poor timing of evaluation relative to incentive disbursement (objective 1). Although we did not find an impact on the motivation constructs measured, PBF increased collegial support and worker empowerment, and, in a time of transitioning implementing partners, decreased against desire to leave (objective 2). CONCLUSION: Areas for future research include incentivizing meaningful quality- and process-based performance indicators and evaluating how PBF affects the pathway to service delivery, including interactions between motivation and workplace environment factors. (c) 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Beyond coverage: improving the quality of antenatal care delivery through integrated mentorship and quality improvement at health centers in rural Rwanda.
BMC Health Services Research. 2018 Feb 23; 18(1):136.BACKGROUND: Inadequate antenatal care (ANC) can lead to missed diagnosis of danger signs or delayed referral to emergency obstetrical care, contributing to maternal mortality. In developing countries, ANC quality is often limited by skill and knowledge gaps of the health workforce. In 2011, the Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) program was implemented to strengthen providers' ANC performance at 21 rural health centers in Rwanda. We evaluated the effect of MESH-QI on the completeness of danger sign assessments. METHODS: Completeness of danger sign assessments was measured by expert nurse mentors using standardized observation checklists. Checklists completed from October 2010 to May 2011 (n = 330) were used as baseline measurement and checklists completed between February and November 2012 (12-15 months after the start of MESH-QI implementation) were used for follow-up. We used a mixed-effects linear regression model to assess the effect of the MESH-QI intervention on the danger sign assessment score, controlling for potential confounders and the clustering of effect at the health center level. RESULTS: Complete assessment of all danger signs improved from 2.1% at baseline to 84.2% after MESH-QI (p < 0.001). Similar improvements were found for 20 of 23 other essential ANC screening items. After controlling for potential confounders, the improvement in danger sign assessment score was significant. However, the effect of the MESH-QI was different by intervention district and type of observed ANC visit. In Southern Kayonza District, the increase in the danger sign assessment score was 6.28 (95% CI: 5.59, 6.98) for non-first ANC visits and 5.39 (95% CI: 4.62, 6.15) for first ANC visits. In Kirehe District, the increase in danger sign assessment score was 4.20 (95% CI: 3.59, 4.80) for non-first ANC visits and 3.30 (95% CI: 2.80, 3.81) for first ANC visits. CONCLUSION: Assessment of critical danger signs improved under MESH-QI, even when controlling for nurse-mentees' education level and previous training in focused ANC. MESH-QI offers an approach to enhance quality of care after traditional training and may be an approach to support newer providers who have not yet attended content-focused courses.
Toward communities as systems: a sequential mixed methods study to understand factors enabling implementation of a skilled birth attendance intervention in Nampula Province, Mozambique.
Reproductive Health. 2018 Aug 3; 15(1):132.BACKGROUND: Skilled birth attendance, institutional deliveries, and provision of quality, respectful care are key practices to improve maternal and neonatal health outcomes. In Mozambique, the government has prioritized improved service delivery and demand for these practices, alongside "humanization of the birth process." An intervention implemented in Nampula province beginning in 2009 saw marked improvement in institutional delivery rates. This study uses a sequential explanatory mixed methods case study design to explore the contextual factors that may have contributed to the observed increase in institutional deliveries. METHODS: A descriptive time series analysis was conducted using clinic register data from 2009 to 2014 to assess institutional delivery coverage rates in two primary health care facilities, in two districts of Nampula province. Site selection was based on facilities exhibiting an initial increase in institutional deliveries from 2009 to 2011, similarity of health system attributes, and accessibility for study participation. Using a modified Delphi technique, two expert panels-each composed of ten stakeholders familiar with maternal health implementation at facility, district, provincial, and national levels-were convened to formulate the "story" of the implementation and to identify contextual factors to use in developing semi-structured interview guides. Thirty-four key informant interviews with facility MCH nurses, facility managers, traditional birth attendants, community leaders, and beneficiaries were then conducted and analyzed using the Consolidated Framework for Implementation Research through inductive and deductive coding. RESULTS: The two sites' skilled birth attendance coverage of estimated live births reached 80 and 100%, respectively. Eight contextual and human factors were found as dominant themes. Though both sites achieved increases, implementation context differed significantly with compelling examples of both respectful and disrespectful care. In one site, facility and community actors worked together as complementary systems to sustain improved care and institutional deliveries. In the other, community actors sustained implementation and institutional deliveries largely in absence of health system counterparts. CONCLUSION: Findings support global health recommendations for combined health system and community interventions for improved MNH outcomes including delivery of respectful care, and further suggest the capacity of communities to act as systems both in partnership to and independent of the formal health system.
Tackling the hard problems: implementation experience and lessons learned in newborn health from the African Health Initiative.
BMC Health Services Research. 2017 Dec 21; 17(Suppl 3):829.BACKGROUND: The Doris Duke Charitable Foundation's African Health Initiative supported the implementation of Population Health Implementation and Training (PHIT) Partnership health system strengthening interventions in designated areas of five countries: Ghana, Mozambique, Rwanda, Tanzania, and Zambia. All PHIT programs included health system strengthening interventions with child health outcomes from the outset, but all increasingly recognized the need to increase focus to improve health and outcomes in the first month of life. This paper uses a case study approach to describe interventions implemented in newborn health, compare approaches, and identify lessons learned across the programs' collective implementation experience. METHODS: Case studies were built using quantitative and qualitative methods, applying the World Health Organization Health Systems Strengthening Framework, and maternal, newborn and child health continuum of care framework. We identified the following five primary themes in health systems strengthening intervention strategies used to target improvement in newborn health, which were incorporated by all PHIT projects with varying results: health service delivery at the community level (Tanzania), combining community and health facility level interventions (Zambia), participatory information feedback and clinical training (Ghana), performance review and enhancement (Mozambique), and integrated clinical and system-level improvement (Rwanda), and used individual case studies to illustrate each of these themes. RESULTS: Tanzania and Zambia included significant community-based components, including mobilization and sensitization for increased uptake of essential services, while Ghana, Mozambique, and Rwanda focused more efforts on improving the quality of services delivered once a patient enters a health facility. All countries included aspects that improved communication across levels of the health system, whether through district-wide data sharing and peer learning networks in Mozambique and Rwanda, or improved referral processes and systems in Tanzania, Zambia, and Ghana. CONCLUSION: Key lessons learned include the importance of focusing intervention components on addressing drivers of neonatal mortality across the maternal and newborn care continuum at all levels of the health system, matching efforts to improve service utilization with provision of high quality facility-based services, and the critical role of leadership to catalyze improvements in newborn health.
Global Health, Science and Practice. 2018 Jun 27; 6(2):247-248.Add to my documents.
Global Health, Science and Practice. 2018 Jun 27; 6(2):257-259.Add to my documents.
Implementation and results of an integrated data quality assurance protocol in a randomized controlled trial in Uttar Pradesh, India.
Trials. 2017 Sep 7; 18(1):418.BACKGROUND: There are few published standards or methodological guidelines for integrating Data Quality Assurance (DQA) protocols into large-scale health systems research trials, especially in resource-limited settings. The BetterBirth Trial is a matched-pair, cluster-randomized controlled trial (RCT) of the BetterBirth Program, which seeks to improve quality of facility-based deliveries and reduce 7-day maternal and neonatal mortality and maternal morbidity in Uttar Pradesh, India. In the trial, over 6300 deliveries were observed and over 153,000 mother-baby pairs across 120 study sites were followed to assess health outcomes. We designed and implemented a robust and integrated DQA system to sustain high-quality data throughout the trial. METHODS: We designed the Data Quality Monitoring and Improvement System (DQMIS) to reinforce six dimensions of data quality: accuracy, reliability, timeliness, completeness, precision, and integrity. The DQMIS was comprised of five functional components: 1) a monitoring and evaluation team to support the system; 2) a DQA protocol, including data collection audits and targets, rapid data feedback, and supportive supervision; 3) training; 4) standard operating procedures for data collection; and 5) an electronic data collection and reporting system. Routine audits by supervisors included double data entry, simultaneous delivery observations, and review of recorded calls to patients. Data feedback reports identified errors automatically, facilitating supportive supervision through a continuous quality improvement model. RESULTS: The five functional components of the DQMIS successfully reinforced data reliability, timeliness, completeness, precision, and integrity. The DQMIS also resulted in 98.33% accuracy across all data collection activities in the trial. All data collection activities demonstrated improvement in accuracy throughout implementation. Data collectors demonstrated a statistically significant (p = 0.0004) increase in accuracy throughout consecutive audits. The DQMIS was successful, despite an increase from 20 to 130 data collectors. CONCLUSIONS: In the absence of widely disseminated data quality methods and standards for large RCT interventions in limited-resource settings, we developed an integrated DQA system, combining auditing, rapid data feedback, and supportive supervision, which ensured high-quality data and could serve as a model for future health systems research trials. Future efforts should focus on standardization of DQA processes for health systems research. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT02148952 . Registered on 13 February 2014.