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Abstract
BackgroundMaternal and newborn mortality remain unacceptably high in sub-Saharan Africa. Tanzania and Uganda are committed to reduce maternal and newborn mortality, but progress has been limited and many essential interventions are unavailable in primary and referral facilities. Quality management has the potential to overcome low implementation levels by assisting teams of health workers and others finding local solutions to problems in delivering quality care and the underutilization of health services by the community. Existing evidence of the effect of quality management on health worker performance in these contexts has important limitations, and the feasibility of expanding quality management to the community level is unknown. We aim to assess quality management at the district, facility, and community levels, supported by information from high-quality, continuous surveys, and report effects of the quality management intervention on the utilization and quality of services in Tanzania and Uganda.MethodsIn Uganda and Tanzania, the Expanded Quality Management Using Information Power (EQUIP) intervention is implemented in one intervention district and evaluated using a plausibility design with one non-randomly selected comparison district. The quality management approach is based on the collaborative model for improvement, in which groups of quality improvement teams test new implementation strategies (change ideas) and periodically meet to share results and identify the best strategies. The teams use locally-generated community and health facility data to monitor improvements. In addition, data from continuous health facility and household surveys are used to guide prioritization and decision making by quality improvement teams as well as for evaluation of the intervention. These data include input, process, output, coverage, implementation practice, and client satisfaction indicators in both intervention and comparison districts. Thus, intervention districts receive quality management and continuous surveys, and comparison districts-only continuous surveys.DiscussionEQUIP is a district-scale, proof-of-concept study that evaluates a quality management approach for maternal and newborn health including communities, health facilities, and district health managers, supported by high-quality data from independent continuous household and health facility surveys. The study will generate robust evidence about the effectiveness of quality management and will inform future nationwide implementation approaches for health system strengthening in low-resource settings.Trial registrationPACTR201311000681314
Highlights
Introduction of new change topic withIndicatorsDissemination and policy DA exchange D LS 2 AP2LS 3 AP3, etc SupportLS –Learning Session Supervision, coaching and mentoring AP – Action Period cards facilitates the policy dialogue with the Ministry of Health [32].Implementation strategy The implementation strategy in intervention districts in Uganda and Tanzania is aligned within government health structures
It is based on a continuous survey of a total of 18,000 households and six repeat health facility censuses implemented between November 2011 and April 2014 in both intervention and comparison districts, including birth histories with women in reproductive age
Questionnaires are adapted from tools including the Safe Motherhood Needs Assessment, Demographic and health survey (DHS), Multiple Indicator Cluster Survey (MICS), Service Provision Assessment (SPA), and others [36,37,38]
Summary
Introduction of new change topic withIndicatorsDissemination and policy DA exchange D LS 2 AP2LS 3 AP3 , etc SupportLS –Learning Session Supervision, coaching and mentoring AP – Action Period cards facilitates the policy dialogue with the Ministry of Health [32].Implementation strategy The implementation strategy in intervention districts in Uganda and Tanzania is aligned within government health structures. The EQUIP coordinators have been supported during the set-up phase of the project by external QM coordinators These two EQUIP coordinators train other mentors who are part of the government district health teams, guiding the prioritisation of the improvement work topics, preparing and facilitating the learning sessions, and giving continuous support to the QITs in health facilities and communities. QM includes a structured problem-solving methodology, which uses teams to improve quality with continuous plan-dostudy-act (PDSA) cycles, which monitor indicators, identify problems, understand causes, implement solutions, check if solutions are working, and modify solutions as needed This problem-solving approach (called the quality improvement process, among other names) was first used on a large scale in the automobile manufacturing industry in Japan [13] and has increasingly entered the medical field since the 1980s [14,15,16], being used within primary healthcare and in low- and middle-income countries [17]
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