A Framework for Policy Makers, Managers, and Medical Care Providers
University Research Co., LLC (URC)
"...even in a severely resource-constrained environment, gains are possible when managers and front-line providers work together to solve local system challenges and make changes to care delivery processes..."
This framework, developed by the United States Agency for International Development (USAID)'s Applying Science to Strengthen and Improve Systems (ASSIST) project, is designed to help managers and care providers at all system levels to understand common challenges in postpartum family planning (PPFP) service delivery and specific solutions that may help to close these gaps. It outlines a new step-by-step approach to improving PPFP services and outcomes, based on improvement methods that have proven effective in other areas of health care. A case study from work conducted by ASSIST in Niger is provided to orient participants on how to plan, implement, continuously assess, and refine interventions to improve PPFP services.
As noted here, PPFP aims to prevent the high risk of unintended and closely spaced pregnancies during the first year following childbirth. It is one of the highest-impact interventions to avoid increased risk of premature birth, low birth weight, fetal and neonatal death, and adverse maternal health outcomes. However, despite gains in training and family planning (FP) commodities distribution, unmet demand for PPFP services remains high in many countries, resulting in a failure to achieve healthy timing and spacing of pregnancies (HTSP) and indirectly contributing to high rates of maternal and child mortality. The reason is that persistent systemic and quality of care gaps continue to prevent many postpartum women from receiving effective PPFP services in low-resource countries. Major barriers, many of which indicate an entry-point for communication-centred interventions, include:
- Problems at the health facility level - For example, inadequate provider knowledge on the full range of modern contraceptive services and limited competencies in providing PPFP services limit the capacity of frontline health workers to provide quality PPFP services, especially related to anticipatory counseling and follow-up for maintenance of method use. There is also a lack of capacity to design, implement, and monitor PPFP quality improvement efforts. The lack of a private space for PPFP counseling for both the postpartum (PP) woman and her husband is often a barrier, as is the failure to counsel on the lactation amenorrhoea method (LAM) and exclusive breastfeeding until 6 months. In general, lack of clear understanding about recommended nutrition and PPFP practices can be a barrier, as can gaps in integrating PPFP and immunisation services (e.g., there can be lack of a robust health information system that collects information on both services and a lack of communication materials and job aids.)
- Problems at the community and household level - These issues may include limited sexual and reproductive literacy, misconceptions, and limited information about modern FP choices, as well as prevailing cultural norms related to family size, pregnancy intervals, breastfeeding pattern, and sexual activity after birth. Furthermore, gender inequality, women's and adolescents' unemployment, and low economic, social and gender status in the household can be significant barriers to FP in some communities. Traditional practices (like female genital cutting) as well as limited involvement of male partners in reproductive, maternal, newborn, and child health (RMNCH) care can also jeopardise women's access to PPFP.
- Weaknesses in underlying health system functions needed to support PPFP services - For example, national policies, strategies, programmes, and regulatory tools may not consistently promote improved access to and use of FP services as part of the broader RMNCH policy (including limited availability of national standards, guidelines, and protocols reflecting up-to-date, evidence-based PPFP practices). This can be due in part to lack of available and meaningful data and failure to use available data to improve coverage and quality of PPFP - information system challenges that can prevent policymakers from understanding FP needs, priorities, and practices in order to develop and implement evidence-based RMNCH policies and FP programmes. Inadequate human resources planning and management can be manifested in: inadequate medical education (pre-service, in-service), with limited continuous professional development opportunities and lack of maintenance of skills after training; absence of clinical supervision and performance monitoring; limited availability of skilled care providers and community health workers (CHWs), particularly in rural areas; and regulatory barriers preventing non-physician care providers from providing PPFP counseling and inserting intrauterine devices (IUDs) postpartum. There are also barriers related to health financing and essential medicines and technologies.
The experience of ASSIST, managed by University Research Co., LLC (URC), and URC's predecessor health improvement projects in various low- and middle-income settings indicate that quality improvement (QI) approaches can help overcome many of these gaps. The key idea is that improving health care quality needs to focus on all parts of a health care system. The model shown in Figure 1 indicates various elements needed to provide quality health services. These elements are divided into 3 main categories: (i) Structure/Resources (or "inputs") describe the context in which care is delivered, including policies and procedures, infrastructure, staff, financing, and equipment; (ii) Processes are the series of activities needed to provide care, such as medical or laboratory procedures, managing personnel, record and data management, or procurement. (iii) Outcomes refer to the effects of health care on the status of patients and populations. Core principles of improvement include:
- Effective teamwork at all relevant system levels that engages managers, providers, staff, patients, and relevant stakeholders to achieve a common improvement aim;
- An understanding of how processes of care function within a health system and the critical bottlenecks that impede reliable functioning of these health care processes;
- Use of data, tailored to each system level, to continuously measure and track progress toward an explicit improvement aim;
- An understanding and focus on patient needs; and
- Regular shared learning.
The Model for Improvement outlined in Figure 2 involves several steps: developing an aim for improvement (by answering, "what are we trying to accomplish?"); developing a measure that tells you if a change is an improvement; thinking about the changes you could make to help you achieve that aim; and testing the hypothesised solution and collecting data to see if it yields improvement using a Plan-Do-Study-Act (PDSA) cycle (based on the results, decide whether to abandon, modify, or implement the solution).
The paper goes on to apply this Model of Improvement to PPFP. The first step is forming a QI team, which is typically made up of managers, front-line health care workers, staff who are involved in all related processes of care, and people affected by the care (patient, families, and communities). For example, PPFP uptake depends on involvement of facility staff providing maternal and childcare (e.g. staff providing routine primary care for women and babies, or providers involved in nutrition counseling or routine immunisation), pharmacists or staff responsible for providing commodities, and community health workers or community representatives. In addition to adding to the knowledge and experience, these teams "create the energy necessary to encourage others to change, and increase buy-in and reduce resistance to change." Their work should be guided by clear aim(s) that are focused on addressing quality gaps in the demand or provision of PPFP services and regularly testing the progress by tracking small number of indicators. (Tables 6-8 in Annex B provide indicators to monitor coverage and quality of PPFP services, improve client knowledge, attitude, and practices on contraception, and strengthen supportive functions to improve and strengthen the health system. These indicators reflect several documents and the ongoing work of multiple partners including the World Health Organization (WHO), the United Nations Population Fund (UNFPA), USAID, and the Maternal and Child Survival Program, with the contribution of FP experts from all over the world.) The PDSA cycle in next in the process; it consists of 4 major steps leading to a change idea that is then implemented and instituted as part of the everyday care. This involves communicating the change and its benefits within the QI team and beyond.
Common challenges to feasible and sustainable changes created as part of the QI process are outlined in Annex A based on the belief that "[d]iverse settings can learn from each other to overcome common quality and system gaps. Increasingly, many improvement approaches (e.g., collaborative improvement) mobilize teams to work together across health system levels and geographic sites to identify, test, and share successful changes for overcoming important quality and system gaps (e.g., monthly simulated IUD insertion using structured peer-to-peer observation to maintain provider competence). Promoting regular shared learning among teams helps to accelerate and scale up improvement efforts."
To illustrate how this framework looks in practice, a case study from Niger examines the application of improvement methods to strengthen integrated FP into routine PP services. One of the outcomes the facilities focused on was an increase in the percentage of PP women provided with FP counseling. For example, Poudrière Regional Hospital created a special FP position held by a midwife who also served as a QI team leader several years back during a predecessor project. All midwives were part of this QI team, which made changes including (to cite only a few): designation of a special space for counselling, involvement and empowerment of staff from other maternal health services on referring PP women for FP, provision of clear job descriptions to health providers, rotation of midwives with each taking turns staffing the FP counselling room, involvement of new delivery room providers in raising awareness and provision of FP services to women, and revision of the supply chain management system to ensure continuous availability of commodities and thus promote client satisfaction. After implementing the changes, ASSIST-supported sites rapidly improved the integration of FP counseling into routine PP care for women, up from 9% in December 2013 to 86% in August 2014. The 16 facilities also made gains in increasing the percentage of PP women discharged with a modern FP method of choice (0% in December 2013 to 31% in August 2014) and in increasing the percentage of couples counseled for FP (from 0% in December 2013 to 9.4% in August 2014).
The report concludes that: "Learning from successful experiences to initiate, scale up, sustain, and institute PPFP best practices would reduce unmet need on contraception and contribute to end preventable maternal and child deaths."
Email from Kate Fatta to IBP Global Knowledge Gateway, June 2 2016. Image credit: URC Mali, February 2016