Assuring Quality MNH Health Service: The Next Frontier
As a public health-oriented OBGYN who has worked in many resource-challenged countries from Afghanistan to Zanzibar championing low-cost innovative strategies to save women’s lives, I count myself among those individuals with a “healthy disregard for the impossible.” Who would have imagined just 10-15 years ago that three little pills (misoprostol) would help turn the tide against postpartum hemorrhage or that Kenyans living in remote areas would be doing banking via mpesa on their phones. I place a high priority on ensuring women and families, no matter where they live, have quality health services even if that notion seems impossible now.
We have seen a decline of nearly 50 percent in maternal mortality as a direct result of knowing that nothing is impossible if we have a unified global effort to advocate for and implement evidence-based practices to predict, prevent and treat complications of pregnancy and childbirth. And we have now set ourselves the new sustainable development goals that will require an even greater and unprecedented commitment to coverage and quality at scale.
But even as we drive increasing numbers of women to give birth with skilled care in a health facility, and as labor wards across the developing world are filling up, this very same push may be inadvertently compromising what we all want to achieve for mothers – a safe and healthy birth. Why? Because efforts to staff up health facilities with highly motivated, appropriately skilled and culturally capable health workers, and to ensure that robust equipment and sufficient supplies are consistently available—all important for quality services—have not kept pace with the demand we created.
There is a mistaken belief among many that providing high quality health services means increased costs for health systems. In fact quality services result in cost savings while poor quality services drive up costs. In Niger, a 2013 study on the cost effectiveness of introducing a quality improvement intervention in maternity wards showed significant health benefits for women and babies and a decline in the average cost of delivery from $35 to $28. Many studies consistently show this effect.
It makes sense. Consider postpartum hemorrhage, the leading cause of maternal deaths worldwide. When a skilled midwife uses active management of third stage labor to prevent or control severe after-birth bleeding in a woman, that’s one fewer blood transfusion that would have to be done. Early detection and treatment of pre-eclampsia, a pregnancy-related hypertensive condition, can be more easily managed and at less cost than the more serious Eclampsia which is a consequence of undetected or poorly treated preeclampsia. Eclampsia leads to the death of mother and child, and so ensuring that simple evidence-based interventions are delivered with high quality all across the health care system is effective and reduces costs. Industry gets this. That’s why we get the same high quality of Coke in Nairobi as you would in rural Kisumu in Kenya. We need to do the same in health.
Ensuring quality services is achievable and here’s how:
- Invest in preservice education that is better governed by accreditation standards. Educate, train and equip students in midwifery, nursing and medical schools so that they are proficient in critical skills immediately on graduation and do not require long periods of internship, supervised practice and expensive in-service training so they can immediately start saving lives.
- Set and be committed to staff up health facilities to a level that supports and encourages skilled, humanistic care and a culture of quality and where we truly believe that our single most important resource is the human resource.
- Invest in helping frontline health providers maintain and enhance their skills through greater on-the-job training in their own facilities, taking advantage of new digital technologies instead of taking them out of the health facility and depleting already understaffed centers.
- Keep quality improvement approaches local within institutions, both in terms of provider adoption of quality standards as well as how they will monitor and act on gaps, and reward the achievement of quality standards;
- Keep it simple. For example, the Safe Childbirth Checklist has proven low-cost and effective as shown recently in Rajasthan, India.
- Where staffing and supplies issues have been solved, promote clinical governance by making data visible to both providers and consumers of health services using labor ward dashboards that monitor staffing ratios, time taken between decisions and actions as is occurring in Indonesia.
- Remember that even health workers have rights!
Ensuring the quality of health care services must remain at the center of our global health work if we are to end preventable deaths of mothers and babies. In addition to saving lives, this focus on quality has the potential to create a powerful ally – a class of health consumer who champions and demands the level of health care and treatment that all people deserve.
Photo: MCHIP/Karen Kasmauski