Closing the quality gap : investigating health system bottlenecks and quality improvement strategies for maternal and newborn care in Sub Saharan Africa, focusing on Tanzania

University dissertation from Stockholm : Karolinska Institutet, Dept of Public Health Sciences

Abstract: BACKGROUND: Despite substantial gains in survival in the past three decades, around 200,000 maternal deaths, 1 million newborn deaths and 1 million stillbirths occur annually in Sub Saharan Africa (SSA). The majority of these could be averted by effective medical interventions, but implementation in the context of under-resourced health systems is a challenge. The content of care received by mothers and newborns is therefore often of poor quality and the discordance between increased utilisation of care without the expected corresponding gains in survival is referred to as the quality gap. Closing this quality gap demands an understanding of its underlying determinants, approaches to measure its characteristics and effective improvement strategies. AIM: To assess implementation bottlenecks in district health systems, and evaluate strategies to address these, in order to contribute to closing the quality gap in maternal and newborn care in Sub Saharan Africa METHODS: Study I was a multiple case study comparing attributes related to use of Clinical Practice Guidelines (CPGs) for maternal health in Burkina Faso, Ghana and Tanzania, focusing on their content and format, using document review and key informant interviews. Study II was a cross-sectional study where household and health facility data was linked to estimate effective coverage, the extent to which interventions were implemented as intended, of five key maternal and newborn health interventions, and to identify bottlenecks in their implementation in rural Tanzania. Study III was a qualitative study using a grounded theory approach to analyse 17 health worker interviews, examining the underlying conditions for care provision and health workers’ perceptions of what constitutes quality of care (QoC). Study IV was a qualitative process evaluation of a collaborative quality improvement (QI) intervention in rural Tanzanian health facilities. Health workers’ perceptions of the components of the intervention was analysed through a deductive theory driven approach, utilising the i-PARIHS framework as a lens, to elucidate contributors to mechanisms of effect. RESULTS: While the content of national CPGs correlated well with WHO guidelines, deficiencies in their format in terms of usability and applicability may limit implementation by health workers in practice (Study I). Effective coverage of maternal and newborn health interventions varied between 3% and 49% in the target populations despite high utilisation of health services; the implementation bottlenecks being similar within, but different between, districts (Study II). Unpredictability was identified as the fundamental condition for maternal and newborn care provision and an important determinant of quality (Study III). The components of collaborative QI interpreted as contributing to mechanisms of effect were: (1) improvement topics with a high degree of fit with existing practice; (2) run-charts using local data to monitor progress; (3) mentoring and coaching in individual health facilities. (Study IV). CONCLUSIONS: Improving the format of CPGs for maternal and newborn care could increase their usability and applicability, and therefore implementation, by health workers in practice (Study I). Estimating effective coverage in conditional stages along an implementation pathway can help to identify bottlenecks within health systems. Differences between districts reveal the utility of analysing bottlenecks at this level (Study II). Increasing predictability of health facility readiness, and focusing on the experiences of health workers, should be prioritised in order to improve QoC (Study III). Focusing on intervention components which meet the perceived needs of health workers may enhance mechanisms of effect and result in greater improvements in QoC and could also be used to guide harmonisation between different QI approaches (Study IV).

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