The COVID-19 pandemic: A call to action for health systems in Latin America to strengthen quality of care.

The Covid-19 and other recent pandemics has highlighted existing weakness in health systems across the Latin-America and the Caribbean (LAC) region to effectively prepare for and respond to Public Health Emergencies. It has been stated that quality of care will be among the most influential factors on Covid 19 mortality rates and low systems performance is the common case in these countries. More comprehensive and system level strategies are required to address the challenges. These must focus on redesigning and strengthening health systems to make them more resilient to the changing needs of populations and based on quality improvement methods that have shown rigorously evaluated positive effects in previous local and regional experiences. A call to action is being made by the Latin American Consortium for Quality, Patient Safety and Innovation (CLICSS) and they provide specific recommendations for decision makers.

Feasibility of community level interventions for pre-eclampsia: perspectives, knowledge and task-sharing from Nigeria, Mozambique, Pakistan and India.

Hypertensive disorders of pregnancy (HDP), particularly pre-eclampsia and eclampsia, remain one of the leading causes of maternal mortality and are contributory in many foetal/newborn deaths. This editorial discusses a supplement of seven papers which provide the results of the first round of the CLIP (Community Level Interventions for Pre-eclampsia) Feasibility Studies. These studies report a number of enablers and barriers in each setting, which have informed the implementation of a cluster-randomized trial (cRCT) aimed at reducing pre-eclampsia-related, and all-cause, maternal and perinatal mortality and major morbidity using community-based identification and treatment of pre-eclampsia in selected geographies of Nigeria, Mozambique, Pakistan and India. This supplement unpacks the diverse community perspectives on determinants of maternal health, variant health worker knowledge and routine management of HDP, and viability of task sharing for preeclampsia identification and management in select settings. These studies demonstrate the need for strategies to improve health worker knowledge and routine management of HDP and consideration of expanding the role of community health workers to reach the most remote women and families with health education and access to health services.

Antenatal corticosteroids for management of preterm birth: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Preterm birth complications are the leading cause of deaths for children under five years. Antenatal corticosteroids (ACS) are effective at reducing mortality and serious morbidity amongst infants born at <34 weeks gestation. WHO guidelines strongly recommend use of ACS for women at risk of imminent preterm birth where gestational age, imminent preterm birth, and risk of maternal infection can be assessed, and appropriate maternal/newborn care provided. However, coverage remains low in high-burden countries for reasons not previously systematically investigated. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for ACS. RESULTS: Eleven out of twelve countries provided data in response to the ACS questionnaire. Health system building blocks most frequently reported as having significant or very major bottlenecks were health information systems (11 countries), essential medical products and technologies (9 out of 11 countries) and health service delivery (9 out of 11 countries). Bottlenecks included absence of coverage data, poor gestational age metrics, lack of national essential medicines listing, discrepancies between prescribing authority and provider cadres managing care, delays due to referral, and lack of supervision, mentoring and quality improvement systems. CONCLUSIONS: Analysis centred on health system building blocks in which 9 or more countries (>75%) reported very major or significant bottlenecks. Health information systems should include improved gestational age assessment and track ACS coverage, use and outcomes. Better health service delivery requires clarified policy assigning roles by level of care and cadre of provider, dependent on capability to assess gestational age and risk of preterm birth, and the implementation of guidelines with adequate supervision, mentoring and quality improvement systems, including audit and feedback. National essential medicines lists should include dexamethasone for antenatal use, and dexamethasone should be integrated into supply logistics.

Validity of self-assessment in a quality improvement collaborative in Ecuador.

OBJECTIVE: Health care quality improvement (QI) efforts commonly use self-assessment to measure compliance with quality standards. This study investigates the validity of self-assessment of quality indicators. DESIGN: Cross sectional. SETTING: A maternal and newborn care improvement collaborative intervention conducted in health facilities in Ecuador in 2005. PARTICIPANTS: Four external evaluators were trained in abstracting medical records to calculate six indicators reflecting compliance with treatment standards. INTERVENTIONS: About 30 medical records per month were examined at 12 participating health facilities for a total of 1875 records. The same records had already been reviewed by QI teams at these facilities (self-assessment). MAIN OUTCOME MEASURES: Overall compliance, agreement (using the Kappa statistic), sensitivity and specificity were analyzed. We also examined patterns of disagreement and the effect of facility characteristics on levels of agreement. RESULTS: External evaluators reported compliance of 69-90%, while self-assessors reported 71-92%, with raw agreement of 71-95% and Kappa statistics ranging from fair to almost perfect agreement. Considering external evaluators as the gold standard, sensitivity of self-assessment ranged from 90 to 99% and specificity from 48 to 86%. Simpler indicators had fewer disagreements. When disagreements occurred between self-assessment and external valuators, the former tended to report more positive findings in five of six indicators, but this tendency was not of a magnitude to change program actions. Team leadership, understanding of the tools and facility size had no overall impact on the level of agreement. CONCLUSIONS: When compared with external evaluation (gold standard), self-assessment was found to be sufficiently valid for tracking QI team performance. Sensitivity was generally higher than specificity. Simplifying indicators may improve validity.

Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation.

OBJECTIVE: To systematically develop evidence-based bundles for care of postpartum hemorrhage (PPH). METHODS: An international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated "GRADE Evidence-to-Decision" framework. Twenty-three global maternal-health experts participated in the development process, which was informed by a systematic literature search on bundle definitions, designs, and implementation experiences. Over a 6-month period, the expert panel met online and via teleconferences, culminating in a 2-day in-person meeting. RESULTS: The consultation led to the definition of two care bundles for facility implementation. The "first response to PPH bundle" comprises uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage. The "response to refractory PPH bundle" comprises compressive measures (aortic or bimanual uterine compression), the non-pneumatic antishock garment, and intrauterine balloon tamponade (IBT). Advocacy, training, teamwork, communication, and use of best clinical practices were defined as PPH bundle supporting elements. CONCLUSION: For the first response bundle, further research should assess its feasibility, acceptability, and effectiveness; and identify optimal implementation strategies. For the response to refractory bundle, further research should address pending controversies, including the operational definition of refractory PPH and effectiveness of IBT devices.

Managing hundreds of improvement teams.

Recognizing the notable scale of USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project activities and sizable number of improvement teams, which in some cases is close to 1,000 improvement teams managed in one country at a point in time, we sought to answer the questions: How do we manage hundreds of improvement teams in one country alone? How do we manage more than 4,000 improvement teams globally? The leaders of our improvement programs manage such efforts as though they are second-nature, without pointing to the specific skills and strategies needed to manage thousands of teams. This paper was developed to capture the lessons, considerations, and insights shared in discussions with leaders on the USAID ASSIST Project, including country Chiefs of Party and Regional Directors. More specifically, this paper seeks to describe what is involved in scaling up and managing large numbers of improvement teams. Through focus group discussions and individual interviews, participants discussed the key skills, strategies, and lessons needed to successfully manage large numbers of teams on the USAID ASSIST Project. We concluded that the six key components in managing large numbers of teams are 1) leadership; 2) management structures and capacities; 3) clear and open communication; 4) shared learning, collaboration, and support; 5) ownership, engagement, and empowerment; and 6) partnerships. We further analyzed these six components as being interrelated to one another based on the relationship between culture, strategy, and technique in implementing quality improvement activities.

Evaluation of an Intervention to Improve Essential Obstetric and Newborn Care Access and Quality in Cotopaxi, Ecuador.

BACKGROUND: Despite improvements in health-care utilization, disadvantages persist among rural, less educated, and indigenous populations in Ecuador. The United States Agency for International Development-funded Cotopaxi Project created a provincial-level network of health services, including community agents to improve access, quality, and coordination of essential obstetric and newborn care. We evaluated changes in participating facilities compared to non-participating controls. METHODS: The 21 poorest parishes (third-level administrative unit) in Cotopaxi were targeted from 2010 to 2013 for a collaborative health system performance improvement. The intervention included service reorganization, integration of traditional birth attendants (TBAs) with formal supervision, community outreach and education, and health worker technical training. Baseline (n = 462) and end-line (n = 412) household surveys assessed access, quality and use of care, and women's knowledge and practices. TBAs' knowledge and skills were assessed from simulations. Chart audits were used to assess facility obstetric and newborn care quality. Provincial government data were used for change in neonatal mortality between intervention and non-intervention parishes using weighted linear regression. RESULTS: The percentage of women receiving a postnatal visit within first 2 days of delivery increased from 53 to 81 in the intervention group and from 70 to 90 in the comparison group (p ≤ 0.001). Postpartum/counseling on newborn care increased 18% in the intervention compared with 5% in the comparison group (p ≤ 0.001). The project increased community and facility care quality and improved mothers' health knowledge. Intervention parishes experienced a nearly continual decline in newborn mortality between 2009 and 2012 compared with an increase in control parishes (p ≤ 0.001). CONCLUSION: The project established a comprehensive coordinated provincial-level network of health services and strengthened links between community, primary, and hospital health care. This improved access to, quality, use, and provision of essential obstetric and neonatal care and survival. Ecuador's Ministry of Health is scaling up the model nationally.

Sustainable scale-up of active management of the third stage of labor for prevention of postpartum hemorrhage in Ecuador.

OBJECTIVE: To analyze the Ecuadorian experience regarding the adoption, scale-up, and institutionalization of active management of the third stage of labor (AMTSL) for prevention of postpartum hemorrhage via continuous quality improvement (CQI) processes. METHODS: Average AMTSL implementation rates for women with vaginal deliveries were compared using unweighted provincial aggregate data from facilities participating in 3 phases of AMTSL programming. Months taken to implement AMTSL at 80% or more and 90% or more compliance were compared across phases. RESULTS: Rate of oxytocin administration during the first 3 months was 5.0% in phase 1, 9.8% in phase 2, and 72.2% in phase 3 (P≤0.001 vs phases 1 and 2). The average number of months provinces took to increase oxytocin administration to 80% or more and 90% or in more women with vaginal deliveries was, respectively, 21.6±18.7 and 30.6±16.4 in phase 1, 23.5±15.1 and 30.1±14.9 in phase 2, and 4.7±4.9 (P≤0.01 vs phase 1; P≤0.001 vs phase 2) and 4.0±3.4 (P≤0.001 vs phases 1 and 2) in phase 3. By December 2009, AMTSL implementation was sustained at 90% or more in all provinces. CONCLUSION: CQI processes identified resistance and operational barriers, and developed mechanisms to overcome them.

Increasing compliance with maternal and child care quality standards in Ecuador.

OBJECTIVE: To determine the effects of hospital quality assurance interventions on compliance with clinical standards, availability of essential drugs, client satisfaction, and utilization. DESIGN: Quasi-experimental, prospective study with four intervention hospitals and four control hospitals. All eight facilities were purposively selected and of comparable complexity. SETTING: Ministry of Health secondary care facilities in Ecuador. INTERVENTIONS: Facility-based quality improvement teams, job clarification, standards communication, refresher training, strengthening hospital pharmacy committees, monthly monitoring of compliance indicators, and formation of users' committees. MEASURES: Compliance with input and process standards, utilization of services, and patient satisfaction were measured monthly in both groups through review of clinical and administrative records, exit interviews, and patient satisfaction surveys. RESULTS: After 12 months, the quality assurance interventions produced rapid increases in compliance with clinical standards in the intervention hospitals as compared with the control group. These improvements appeared as early as 2 months after the onset of the interventions. No differences were found between intervention and control groups in terms of trends in utilization patterns or client satisfaction. CONCLUSION: Quality assurance interventions made a difference in technical quality of care. Patient satisfaction and utilization do not appear to be directly associated with short-term improvements in compliance with clinical standards. Quality improvement interventions may require longer periods and a specific aim at clients' needs to demonstrate effects on utilization and satisfaction outcome variables.

El Mejoramiento de la calidad de las actividades de control de enfermedades diarréicas incluyendo el Cólera / Improvement of the quality of activities of control of diarrhoeal illnesses including Cholerae

Desde 1993 el personal local de salud del Ministerio de Salud de las áreas de Suchitepéquez y El Quiché en Guatemala, y del departamento de Chalatenango en El Salvador, con el apoyo del INCAP, realizan esfuerzos en procesos del mejoramiento de la calidad de los servicios dentro de las actividades de Control de Enfermedades Diarréicas (CED) y el Cólera. El proceso del mejoramiento de la calidad comprende las evaluaciones rápidas de calidad, priorización de problemas e identificación de opciones de solución y la implementación, supervisión y monitoreo del mejoramiento de la calidad. En esta Monografía se describe en forma breve la experiencia de las áreas de salud de Guatemala y El Salvador, que se han lanzado a la aplicación de cada una de las etapas mencionadas anteriormente. En los apéndices se proveen las herramientas e instrumentos que se han utilizado en este desarrollo.