QUALITY SESSION Session Facilitator: Debbie Armbruster (USAID)

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Quality Session Overview | Barbara Rawlins (MCHIP)

Impact at scale requires effective (i.e., quality) coverage with high impact interventions. What is
quality? The World Health Organization (WHO) defines six dimensions of quality - effectiveness,
safety, acceptability, efficiency, accessibility, and equitability. Quality for a service for any of these
dimensions needs to be defined, measured, and improved. Any quality improvement system should
be effective and sustainable at scale. The four presentations in this session will describe quality
measurement and improvement approaches for reproductive, maternal, newborn and child health
care developed and/or supported over the life of MCHIP. These approaches the MCHIP Quality
of Care (QoC) health facility survey, the Standards-Based Management and Recognition (SBM-R)
approach, the Regular Appraisal of Program Implementation in Districts (RAPID) approach, and
Respectful Maternity Care (RMC) address the first three WHO dimensions of quality
(effectiveness, safety, acceptability). The last two WHO dimensions of quality (accessibility,
equitability) are covered under the Community session of this meeting. Moving forward, continued
investments are needed not only to scale up key quality improvement (QI) approaches but also for
improved measurement and learning to answer questions about effectiveness and sustainability.

Quality of Care for Labor and Delivery Services: Findings and Implications from Six East and
Southern African Countries | Sheena Currie | MCHIP

MCHIP conducted a series of health facility assessments from 2010 to 2012 to measure the quality
of antenatal (ANC) and labor and delivery (L&D) care services in 7 countries in East and Southern
Africa. Results have been used by all countries to inform quality improvement efforts, including
policy and service delivery changes. A notable feature of the assessments is the use of direct
observation of L&D and ANC care (in addition to provider interviews and an audit of supplies and
equipment). Direct observation offers a better picture of the quality of service delivery than only
facility readiness because even when supplies and equipment are present, interventions may still
not be provided at all or according to standard. The assessment measures WHO quality
dimensions of effectiveness, safety & acceptability (i.e., respectful care). The assessment tool is
being simplified based on an analysis done to identify a smaller set of indicators that reliably
measure the quality of L&D care. The streamlined L&D observation checklist was field tested in
Tanzania in March with district health management teams and is being revised. The simpler tool
is being promoted for use on a routine basis as part of quality improvement or supervision. The
original L&D observation checklist has now become an optional module of the Service Provision
Assessment (SPA) and is being applied in the Bangladesh and Malawi SPAs.

Standards-Based Management and Recognition in Zimbabwe | Hillary Chiguvare | MCHIP
Zimbabwe

The Standards Based Management and Recognition (SBM-R) approach to quality improvement
(QI) was implemented in 17 facilities in two districts of Manicaland Province, Zimbabwe. Services
covered were maternal, newborn and child health. After initial assessments, improvement
activities included training in key maternal and newborn care practices, strengthening
supervision, physical refurbishments, and reorganizing services. Quality scores for maternal and
newborn health services improved from an average attainment of 25% of standards to an average
of 82%. Use of key maternal and newborn health practices improved (for instance, Active
Management of the 3rd Stage of Labor improved from 87% to 99.8%). There were not enough
maternal deaths for a trend analysis, but late stillbirth and very early newborn deaths declined
steadily from a quarterly total of 196 (Q4, 2010) to 109 (Q3, 2013). This QI approach is being
scaled up by the Ministry of Health (MOH) in other parts of Zimbabwe. Globally, the Maternal and
Child Survival Program is working on improving the sustainability of SBM-R by streamlining
tools, using mHealth and job aids, and linking to supervisory and incentive mechanisms.

RAPID Quality Improvement for Immunizations in India | Gunjan Taneja| MCHIP India

Regular Appraisal of Program Implementation in Districts (RAPID) is an integrated supportive
supervision approach for quality improvement and increased coverage of Routine Immunization.
The essence of the approach is overall improvement of immunization service delivery with a health
systems strengthening program. The RAPID approach employs trained supervisors, guided by a
checklist, assessing routine immunization services in all sub-district cold chain points. On-site
corrections and capacity building are integrated with data collection. Each facility is categorized as
good, average or poor based on their performance. Immediate feedback is provided at every level
and follow-up visits are done to check progress. RAPID assessments are done for all districts over
a short period of time every 3-6 months and generate systematic plans that facilities follow
themselves. Program management and practices have improved leading to improved quality
immunization coverage. In Jharkhand, the group of facilities went from a mix of 36% poor, 55%
average and 9% good in Round 1 to 0% poor, 27% average and 73% good in Round 6. The approach
has been scaled up with Government of India funds across Jharkhand, Haryana, Madhya Pradesh,
Odisha and Uttarakhand. It has also been expanded with UNICEF support in 32 districts in Uttar
Pradesh. Madagascar, Kenya and Tanzania are also now implementing the approach.

Respectful Maternity Care in Mozambiques Model Maternities | Veronica Reis | MCHIP

Respectful Maternity Care (RMC), also known as humanization of childbirth care, is an approach
centered on the individual and based on principles of respect for human rights and promotion of
evidence-based care. It recognizes womens preferences and the needs of women and newborns.
RMC was implemented as an integral part of the improvement of quality (that includes the clients
perspective [RMC] as well as the providers technical perspective) in the Mozambique Model
Maternities Initiative, which includes facilities covering 1/3 of institutional deliveries. Indicators of
RMC are now integrated into registers. The percentage of women with a birth companion started
near zero in 2009 and has risen to over 50% (Q3, 2013). Also starting from a baseline near zero,
over 30% of women gave birth in traditional vertical or squatting positions in the last quarter of
2013. Indicators of technical quality of care have also improved. Correct partograph use is 75% and
Active Management of the Third Stage of Labor (AMTSL) near 100%. Institutional maternal
mortality has steadily declined by 40% over that period. The Mozambique MOH has incorporated
respectful (humanized) care as an integral element of quality across multiple clinical services, led
by the recently established national Quality and Humanization of Care structure. Globally, the
Maternal and Child Survival Program will continue working on respectful care with the USAID
ASSIST Project, WHO, and others to define, measure, and improve this aspect of quality.

Questions and Answers in plenary | facilitated by Debbie Armbruster (USAID)