Transcript Learning Session 2 - National

Accelerating Spread of Community-Based
Strategies to Reduce Maternal, Newborn
and Child Health Challenges in Ghana
by
Nana A. Y. Twum-Danso, MD, MPH
Director, Project Fives Alive!
Institute for Healthcare Improvement
5th Annual International Conference of the African Science Academy
Development Initiative
La Palm Royal Beach Hotel, Accra, Ghana
November 10-11, 2009
Presentation Outline
• Background
• Successful CommunityBased Strategies
• Summary
BACKGROUND
Background (1/6):
Aim of Project Fives Alive!
Assist and accelerate
Ghana's faith-based and
public health services
efforts to achieve MDG4
through the application
of quality improvement
methods
Background (2/6):
Drivers of Under-5 Deaths in Ghana
Community Level
Health Facility Level
1. Low/no risk awareness, prevention
& management
1. Lack of patient-centeredness in
design of health services
2. Low valuation of women &
children’s lives
2. Irregular and/or inappropriate
preventive care
3. Lack of financial means and/or
health insurance
3. Late and/or inappropriate
therapeutic care
4. Distance from health services
4. Unreliable referral system from
clinics to hospitals
5. Unattractive health services (staff
attitudes, cultural incompatibility etc.)
5. Inequity in health services provision
6. Unreliable generation & movement
of health information
Background (3/6):
Enablers of Under-5 Survival in Ghana
Resources

Knowledge & Training

Systems Approach
Background (4/6):
QI Strategies - The Model for Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
• Method of continuous quality
improvement
• Provides a framework work for
developing and testing change
ideas, learning and re-design
• Emphasizes small changes
that are non-threatening and
non-disruptive
• Relies on input and ideas from
frontline providers
Source: Associates for Process Improvement
Background (5/6):
QI Strategies – Improvement Collaborative Network
Improvement Collaborative Network
Health
Facilities
ACTIVITY
PERIOD
Repeated
improvement
cycles:
Assessment
and Design
Period
Learning
Session 1
ACTIVITY
PERIOD
Repeated
improvement
cycles:
Learning
Session 2
Wave 1
26 clinics & 2
hospitals from 4
districts/dioceses
Learning
Session 3
Intensive support from project staff & DHMT
12 -24 months
© Institute for Healthcare Improvement
Start Small, Accelerate
Learning & Scale-up Rapidly
Jul’08 to present
Background (6/6):
Focus of QI Work
• Care Pathway
SELECTION OF
SUCCESSFUL STRATEGIES
Antenatal Care:
Activate CBVs to identify pregnant women in community early,
provide health education, refer to clinic for ANC, midwife follows-up
ANC registration in 1st Trimester - Damango MCH, West
Gonja District, NR, Jan’08 to Sept’09
% ANC registrants in 1st Trimester
50
NHI free for maternity &
early infant care; small scale
testing of pregnancy registers
Scale-up of pregnancy
registers from 4 to 72
communities
40
30
20
10
0
% 1st trim
Median
Skilled Delivery:
Engage TBAs to accompany labouring women to health
facility; TBA can stay and serve as delivery companion
% of deliveries attended by skilled personnel
Skilled Delivery Coverage - St. Joseph PHC/Maternity Clinic,
Nakolo, Kassena-Nankana West District, UER, Jan’08 to Sept’09
100
80
60
40
20
NHI free for maternity
& early infant care
TBA engagement
started
0
% of Skilled Del
Median
Skilled Delivery:
Engage chiefs & elders on risks of labour and delivery &
enlist their help in promoting skilled delivery
Skilled Delivery Coverage in Yagha Sub-District, Jirapa District,
UWR, Jan’08 to Sept’09
100
80
Chiefs modify
traditional practice in
1/9 communities
NHI free for
maternity &
young infants
%
60
40
Spread to 3/9
Communities
20
0
Percent Skilled Delivery
Median
Skilled Delivery:
Video show in community on risks of unskilled delivery
followed by Q&A session and health promotion
Skilled Delivery Coverage in Hain Sub-District, Jirapa District,
UWR, Jan’08 to Sept’09
100
Video show in 1 community;
NHI free for maternity and
young infants
Spread video to 5
communities
80
%
60
40
20
0
Percent Skilled Delivery
Median
Skilled Delivery:
Mobile telephone contact between labouring women and
health staff for transport or domiciliary midwifery
Skilled Delivery Coverage in Wiaga Sub-District, Builsa District,
UER: Jan'08 to Sept'09
100
Free NHI maternity &
early infant care
Midwife's phone #
given out during ANC
TBA engagement
started
% of skilled delivery
80
60
40
20
0
Jan'08 Feb
Mar
Apr May
Jun Jul'08 Aug Sept Oct
% of Skilled Del
Nov
Dec Jan'09 Feb
Median
Mar
Apr May
Jun Jul'09 Aug Sept
Postnatal Care:
Home visits by health staff on Day 1 or 2 for neonates born
at home and home visits on Day 6 or 7 for all neonates
Early PNC Coverage in Zorko sub-district, Bongo District, UER,
Jan’08 to Sept’09
60
Free NHI for pregnant
women & infants launched
# of Neonates
50
40
30
20
Testing of new draft
GHS early PNC policy
10
0
Jan'08 Feb
Mar
Apr
May
Jun Jul'08 Aug Sept
Oct
Nov
Dec Jan'09 Feb
Mar
Apr
May
PNC Registrants
Received 1st PNC within 2 days of life
Received 2nd PNC wihtin 7 days of life
Clinic's Target for PNC registrants
Jun
Jul
Aug Sept
Postnatal Care:
Home visits by CBVs on Day 4 to screen for danger signs and
remind mothers to follow up at health center on Day 6 or 7
Early PNC Coverage in Samoa sub-district, Lambussie-Karne District,
UWR, Jan'08 to Sept'09
40
NHI made free for maternity
and early infant care
Volunteers engaged to do
home visit on day 4
# of neonates per month
35
Testing of draft GHS
early PNC policy started
30
25
20
15
10
5
0
No. of Registrants
No. Received 1st PNC within 2 days live
No.Received 2nd PNC within 7 days of live
Expected Live Births
Change Package:
Development of a change package for scale up
• Data were collected on each change idea tested
• 6 to 12 months of baseline data and at least 6 months of postintervention data
• Used time-series analysis to determine successful change ideas.
• Developed strict criteria for determining successful change ideas:
Score
0
1
2
3
Definition
No evidence or suggestions of improvement
Suggestions of improvement but not enough time to
meet test of evidence
Evidence of improvement but not sustained
OR not enough time to assess sustainability
Evidence of improvement which has been sustained
Scaling Up Change Package
• Change Package
Wave 2
~300 QI teams from
38 districts
Sept’09 to Jun’11
SUMMARY
Summary
• Local knowledge, innovation and testing of changes at the
community level can reduce delay in seeking care for MNCH
• Local generation and use of data key to:
– Frontline health provider empowerment to develop and test
changes iteratively for continuous improvement
– Improving data quality from primary sources
• Processes across care continuum can be accelerated with
Improvement Collaborative Network model through:
– peer-to- peer learning
– deliberate spreading of successful change ideas/best practices
• Change package can facilitate spread of local successes or best
practices on a large scale to achieve higher coverage and
improved health outcomes in non-innovation sites
Can the achievement of MDG4 in Ghana be
further accelerated?
We believe we can!
Acknowledgements
• Team
–
–
–
–
–
–
–
–
–
George B. Akanlu
Isaac A. Amenga-Etego
Ireneous N. Dasoberi
Solomon A. Atinbire
Phoebe Bala
Francisca Bagna
Chrysanthus Kubio
James Tobiga
Pierre M. Barker
• Institutions
– Ghana Health Service
– National Catholic Health
Service
– Institute for Healthcare
Improvement
– Bill & Melinda Gates
Foundation