Quality of care: how to achieve
universal coverage with patient safety?
Dr Elizabeth Mason
Director, Department of Maternal, Newborn, Child and Adolescent Health
World Health Organization
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
A great challenge …
EVERY YEAR:
 6.9 million children die before their 5th birthday
– Approx. 3 million newborn babies in the first
month of life
 287,000 women die due to complications of
pregnancy and childbirth
– 3 million stillbirths
Most of these tragedies are
preventable and can be prevented
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Maternal mortality reducing – but not enough
900
Under-five Mortality Rate per 1000 live births
800
700
600
500
400
300
200
MDG Goal
100
0
1990
1995
Africa
Western Pacific
2000
2005
Eastern Mediterranean
Americas
Source: WHO/UNICEF/UNFPA/The World Bank. Trends in Maternal Mortality: 1990 to 2010.
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
2010
South-east Asia
Europe
Under 5 mortality reducing but neonatal mortality slower
150
Target: To reduce by two-thirds, between 1990 and 2015, the
under-five mortality rate
125
100
If recent trends
75
continue
50
25
To achieve
MDG
0
1980
1985
1990
1995
U5MR
Source: Levels and Trends in Child Mortality, UN-IGME Report 2012
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
2000
NNMR
2005
2010
Care packages available for mother and newborn
Pregnancy
Care
Birth care
Postnatal
care
Contemporary Debates
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UCL perspective.
3 October 2012
• Antenatal care package, particularly:
• Identification and treatment of syphilis, malaria, tuberculosis and HIV
• Identification and treatment of hypertensive disease in pregnancy
• For women at high risk of preterm birth:
• Tocolytics to slow down preterm labour
• Antenatal corticosteroids
• Antibiotics for pPROM to prevent infection
• Drying immediately after birth, warming, skin-to-skin and delayed bathing
• Neonatal resuscitation if not breathing at birth
• Delayed cord clamping
• Early and exclusive breastfeeding
• Thermal care
• preterm babies: Kangaroo Mother Care, overhead heaters, incubators
• Exclusive breastfeeding
• preterm babies: support for mothers, cup or tube feeding of expressed breast milk
• Hand washing, hygienic cord care
• Care for very preterm babies – feeding, warmth, breathing
… and for different levels of the health system
Home and community
• Home visits during pregnancy and after birth
First level health facilities
• Skilled care during labour and childbirth
• Essential newborn care including resuscitation if required
• PMTCT
Referral facilities
• Management of very preterm babies
• Management of severe infections
• Management of severe asphyxia
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
.. but coverage varies across the continuum of care
100
80
60
40
Source:
Countdown 2012
Report: Median
levels for selected
indicators of
intervention
coverage, all
countries with
available data
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
20
0
56 88 55 13 85 57 41 46 37 73 85 84 83 92 34 55 39 25 33 40 76
Reducing mortality needs coverage with quality
Recognising
problem and
seeking care
Yes
Physical and
Financial
access
Yes
Health Facility
open
No
No
No
 Risk of death
 Risk of death
 Risk of death
All actions
undertaken
together
Yes
Drug/equipment
available?
Yes
Qualified staff
present?
No
No
No
 Risk of death
 Risk of death
 Risk of death
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Yes
WHO MNCAH assessment tools and approaches
Provision of care
P
CO
Experience of care
Maternal
•EMOC
•Maternal death and
morbidity reviews
•IFC/accessability &
Perception of quality
Newborn and
Child
•Health Facility Survey
•Hospital Assessment
•Community health
worker quality
assessment
•Health Facility Survey
•Hospital Assessment
•Community health
worker quality
assessment
Adolescent
•Quality of adolescent
health services
•Quality of adolescent
health services
(community)
MNCH (HS)
•SARA (SAM)
•SPR (MNCAH)
•MNCH household
survey
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
P
User
Assessments and related indicators
Indicators
Emergency Obstetric Care
(EMOC)
EMOC coverage (BEmOC, CEmOC)
Maternal death and
morbidity reviews
Causes of death and morbidity
IFC module (PCA)
Accessibility and perception of quality
Health Facility Survey
(HFS)
Child with pneumonia correctly treated
Child with malaria correctly treated
Hospital Assessment
Patient monitoring, infection control, staffing levels, etc
Community health worker
quality assessment
Proportion of children with cough and fast breathing who are prescribed an antibiotic correctly
Proportion of children with fever who are prescribed an antimalarial (ACT) correctly
Quality of adolescent
health services
Providers are non-judgmental, considerate and easy to relate to
Policies and procedures are in place to guarantee client confidentiality
Adolescents are well informed about the range of services
SARA
Readiness score
MNCH household survey
MNCH coverage of services
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Example: EmOC and HFS implementation
Countries with EmOC assessment (30)
Countries with child HFS (35)
35
su rveys co n d u cted
30
25
20
15
30
10
18
5
0
2001 - 2005 (20 countries)
Contemporary Debates
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3 October 2012
2006 - 2010 (15 countries)
Example: Malawi Short Programme Review
(MoH, 2010)
Quality of child care provided by CHWs
(community health worker assessment draft tool)
100%
90%
79%
80%
70%
60%
(EmOC Assessment tool)
50%
73%
58%
51%
Availability of quality EmOC
55%
40%
50%
30%
40%
30%
47%
20%
20%
10%
0%
Proportion of
children with cough
and fast breathing
who are prescribed
an antibiotic
correctly‡
Proportion of
children with fever
who are prescribed
an antimalarial
(ACT) correctly
Proportion of
children with
diarrhea who are
prescribed ORS
correctly
Proportion of
Proportion of
children without
children with danger
cough and fast
signs needing
breathing who leave
referral who are
the HSA without
referred
having received an
antibiotic
Quality of child care provided in HFs
(Health Facility Survey tool)
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
10%
0%
2%
Basic EmONC (5/210)
Comprehensive EmONC (42/89)
Maternal Death Surveillance & Response system:
Linking Review to Action
QoC improvement
Surveillance
Vital registration
Response
action
Identify
deaths
Review
deaths
Report
deaths
QoC measurement
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Response
MMR tracking
New Tool
Safe childbirth
check list
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Progress
• Feasibility tests in 17 sites in 10 countries
• Pilot field test in one site in India
– Overall 150% increase in adherence to evidence
based practices
– Significant improvement in 28 out of 29 practices
– Insufficient sample size to assess impact
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Pilot Test: Average rate of successful delivery of essential
childbirth practices before and after intervention (p<0.001)
Before
9.8 (9.4, 10.1)
After
25 (24.6, 25.3)
0
5
10
15
20
Essential childbirth practices delivered (n=29)
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
25
30
Pilot Test: Changes in rates of delivery of specific childbirth
practices before and after intervention
At delivery
On admission
% Before (n=405)
% After (n=638)
100
94.1
99.8
97
93.4
97.8
92.1
90
77.1
75.6
80
78.3
73.9
70
60
53.9
50
42.6
40
30
20
10
3.8
2.9
1.3
0
0
Appropriate
maternal
referral*
Part ograph
use
Appropriate Appropriate Appropriate
Birth
Appropriate Intrapartum
maternal preeclampsia maternal HIV companion hand hygiene counseling
infection management prophylaxis present or
management
encouraged
Soon after birth (within one hour)
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
*P value = 0.052; all others p < 0.03
Before discharge
Achieving quality care is possible
Every mother and child
deserves quality health care
Contemporary Debates
in Global Health: the
UCL perspective.
3 October 2012
Thank you