QUALITY OF CARE AND HEALTH

(1)

QUALITY OF CARE AND HEALTH SYSTEMS – AN OPERATIONAL AGENDA

Austen Davis - Norad UiO Seminar 7th October 2014

(2)

BACKGROUND

Disclaimer – this is not an official position from Norad – I am working on these issues for Norad and this is how far I have come struggling with the topic.

Concepts are developed largely in relation to Reproductive, Maternal and Neonatal care (in comparison with under 5 mortality reduction) – as a major case study running troughout the talk

Structure of the talk

1.Is «quality» important?

2.What is quality

3.Difficulties in using the concept of quality 4.Some ways forward?

(3)

IS QUALITY (INCREASINGLY) IMPORTANT?

 Unequal progress against MDG goals -> quality lag (Maternal and Neonatal lag Vs Child)

 New proposed goals more complex -> requiring quality (UHC, NCDs, Risk Reduction)

 Economic «transition» - More domestic ownership and financing

(changing role and importance of ODA)

 Evidence vertical approaches Not Sufficient -> quality deficit

(Moving Beyond Essential Interventions for Reduction of Maternal Mortality – Souza JP, Gulmezoglu AM, Vogel J et al Lancet 2013 381 1747)

(4)

0 200 400 600 800 1000 1200 1400 1600

Nature CB Medico-Nutritional prevention and EMONC

Deaths/100,000 LBs

Country Level Rates

Different Qualities at Different Stages? – When Does Quality" Kick In?

PHC/

Community Approaches

Quality of Care EMONC

(5)

EFFECTIVE INTERVENTIONS?

•FP and Reproductive Health Services

•Nutrition

•Skilled care during pregnancy and delivery

•EOC

•PNC for mother and baby

(6)

HEALTH SYSTEMS STANDARD – DO NOT WORK

CEMONC

BEMONC BEMONC BEMONC BEMONC

(7)

Mcclure et al. IJOG 2007

(8)

Mcclure et al. IJOG 2007

(9)

2. WHAT IS QUALITY

Definitions

Different ethical positions

Different scope – individual, facility, programme, systems?

(10)

DONABEDIAN MODEL – QUALITY IS

EVERYTHING

(11)

QUALITY VS HSS (QUALITY IS ONLY A

BIT)?

(12)

DIFFERENT DEFINITIONS – OVERLAPPING BUT NOT THE SAME

IoM Goodlee Hutton et al Hawkins et al Graham et al Campbell et al

• Effectiveness

• Safety

• Timeliness

• Efficiency

• Equity

• Responsivenes s

• Effective

• Safe

• Good experience

• Timely

• Appropriate

• Uphold

reproductive rights

• Available

• Accessible

• Acceptable

• Quality

• Timely

• Effective

• Appropriate

• Affordable

• Access

• Effectiveness of clinical

• Effectiveness of inter- personal

(13)

QUALITY VS RESOURCES

Is lack of quality just a lack of resources?

QUARITE study Senegal and Mali 15% reduction in mortality

WHO multi-country study

-> BUT Quality is related to resources/costs

(14)

OPERATIONAL UTILITY

Analysis must deliver information that is

Feasible to measure (costs of managing quality)

Timely

Complete (enough) to be of decisional quality

Compelling

Relative (opportunity costs or cognisant of resource constraints)

Feasible to implement

Likely to produce results (good RoI)

(15)

SPECIFIC, DEFINED AND RELATIONAL CONCEPT

Effectiveness

Efficiency Equity

Quality

(16)

AREAS OF INFORMATION NEED TO LOOK AT QUALITY

ACCEPTABILITY

• Better than alternatives

• Respectful

• Valued

ACCESS

• Reachable

• Timely

• Affordable

EFFECTIVE

• Produces desired outcomes

• Affordable

(17)

4. PROMISING WAYS FORWARD

•Mapping

•Breakdowns

•Effective Coverage

•Discrete Choice

Analyse Quality at system level then zero in on bottleknecks or marginal frontiers

(18)

HEAT MAPS (ACCESS)

Figure 12 - Combined walking and road transport times (max 120 minutes) to CEMOC facilities

Figure 13 - Combined walking and road transport times (max 120 minutes) to CEMOC facilities

(19)

BASELINE MATERNAL MORTALITY SURVEYS

19

91 Maternal Deaths

72 Aware of Problem

63 Sought Help

55 Reached Facility

8 Did Not Reach Facility 9 Did Not Seek

Help 19 Not Aware

60% of maternal deaths occurred after a reaching facility, 31% never sought help and 9% died during transport.

46% of deaths to women reaching facilities received treatment within the first hour.

(20)

Effective Coverage (Effectiveness).

Nesbitt RC, Lohela TJ, Manu A, Vesel L, et al. (2013) Quality along the Continuum: A Health Facility Assessment of Intrapartum and Postnatal Care in Ghana. PLoS ONE 8(11): e81089. doi:10.1371/journal.pone.0081089

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0081089

(21)

DISCRETE CHOICE (ACCEPTABILITY)

(KRUK ET AL AJPH 09/2009; VOL 99 NO 9)

(22)

DISCRETE CHOICE

(KRUK ET AL AJPH 09/2009; VOL 99 NO 9)

(23)

START BROAD - ZERO IN – CONTINUOUS MANAGEMENT

System Wide Analysis (Q,E,E,E)

Hi Impact quality concerns/diagnosis

Quality Improvement

Strategies Accountability

Strategies