Reproductive health services in Malawi: An evaluation of a quality improvement intervention
Introduction
The majority of Malawi's 13 million people live in rural areas, where access to good quality health care is limited. Mortality among children under age five has been steadily declining and is on a trajectory to meet the United Nations Millennium Development Goal 4 to reduce child mortality by two-thirds by 2015. Yet maternal and neonatal health indicators are not improving as quickly. The maternal mortality ratio in Malawi remains among the highest in the world, at 807 per 100,000 live births (NSO and UNICEF, 2008). In recent years the proportion of births at health facilities where skilled attendance is available has jumped, moving from 55% in 1992 to 72% in 2010 (NSO and ICF Macro, 2010). However, the quality of emergency obstetric care remains poor according to a national needs assessment (Leigh et al., 2008). Although contraceptive use has increased steadily since 1992, the rate of unplanned pregnancy also remains persistently high (NSO and ICF Macro, 2010).
Nurses and nurse–midwives play a critical role in saving the lives of mothers and young children in sub-Saharan Africa. In Malawi, they comprise the largest group of health professionals (AHWO, 2009) and provide the majority of reproductive health services at the district and sub-district levels (Picazo and Martineau, 2004). With few physicians available, they form the backbone of basic services proven to reduce maternal and neonatal mortality, such as family planning, antenatal and postnatal care, and skilled attendance at birth (Darmstadt et al., 2005, Campbell and Graham, 2006). However, a severe shortage of midwives, nurses and other health professionals has crippled the ability of the health-care system in Malawi to adequately address maternal and neonatal mortality and other pressing health issues (Ministry of Health (MoH)/Malawi, 2004, Palmer, 2006).
In 2004 the Ministry of Health (MoH) launched an Emergency Human Resources Programme (EHRP) to help revitalise the health system (MoH, 2004). It offered financial incentives to recruit and retain health workers, expanded the capacity of pre-service training institutions, and strengthened human resources management (Palmer, 2006, O’Neil et al., 2010). A recent evaluation found that the EHRP has had a considerable impact both on the number of health workers and also on their commitment to remaining in the profession and in Malawi. From 2004 to 2009, the number of health workers grew by 53%. There are now 37 nurses (including midwives) per 100,000 population in Malawi, compared with 29 per 100,000 population in 2004 (O’Neil et al., 2010).
While the EHRP directly addressed chronic understaffing, it did less to overcome deep-seated problems in the work environment that undermine the quality of health services in Malawi. Job performance depends not only on good pre-service education and adequate staffing, but also on a host of other factors ranging from the availability of supplies and equipment to systems providing for continuous learning, supervision, and recognition (Rowe et al., 2005). In their analysis of efforts to reduce maternal mortality, Fauveau and colleagues (2008) have argued that a focus on increasing the number of birth attendants has drawn attention away from the need to improve the quality of care by strengthening their proficiency in key midwifery skills.
The rapid influx of newly trained workers into Malawi's health system makes performance issues especially pressing. The quality of training and supervision offered to nursing and midwifery students has suffered because the EHRP failed to overcome some key problems, such as a shortage of tutors and the difficulty of recruiting qualified students into training programs (Picazo and Martineau, 2004, O’Neil et al., 2010). Pass rates at the 13 training institutions for midwives and nurses in Malawi are declining steeply, with less than half of nursing and midwifery students in the 2010 cohort expected to graduate, according to a report by the Nursing and Midwives Council of Malawi at the 2010 mid-term SWAP review. Given the weaknesses in the education system, inexperienced new nurses entering the workforce are increasingly in need of close support, supervision, and mentoring on the job to raise their skill levels.
However, a series of studies have described a dysfunctional work environment in Malawi's health system that reduces providers' motivation and ability to offer good quality care (Picazo and Martineau, 2004, Muula and Maseko, 2005, Bradley and McAuliffe, 2009, Manafa et al., 2009, McAuliffe et al., 2009). Most health workers lack written job descriptions and must cope with shortages of drugs, supplies, and equipment. There is inadequate mentorship, supervision, recognition, and rewards for service providers. Written standards, targets, and timelines for appraising performance are also largely missing.
The MoH has long recognised the need to improve provider performance and service delivery, and its quality improvement efforts predate the EHRP. In 2001 the MoH launched a Performance and Quality Improvement (PQI) initiative to improve infection prevention practices in hospitals. In 2006 the MoH and the ACCESS Program1 extended the PQI initiative to reproductive health (RH) services in hopes of reducing maternal and newborn morbidity and mortality. The PQI RH intervention has since been scaled up to all 23 district hospitals in Malawi and 33 health centres in four districts.
PQI is based on the Standards-Based Management and Recognition (SBM-R) approach to quality improvement developed by Jhpiego and used in over 30 developing countries worldwide. SBM-R sets evidence-based performance standards and then empowers health-care managers and providers to assess and address gaps between actual and desired performance at their facility (Necochea and Bossemeyer, 2005). The approach is well suited to low-resource settings like Malawi because it is facility-based and focuses on practical solutions, requires little additional manpower or resources, helps transfer learning and motivate health workers, and results in steady improvements.
In Malawi, a Quality Improvement Support Team (QIST) at each facility leads the PQI RH intervention. An external team working in collaboration with the QIST conducts a baseline assessment of services. Then QIST team members and additional hospital personnel analyse the data, determine the causes of performance gaps, design interventions to address gaps, and conduct quarterly internal assessments to assess progress. Results from internal assessments are shared across facilities in a collaborative approach, and progress at individual facilities is benchmarked against baseline measures and the performance of other facilities. Once a facility scores 80% on an internal assessment, it can request an external verification assessment. A score of at least 80% on that assessment earns national recognition as a centre of excellence for reproductive health. The external verification process is repeated annually to monitor adherence and institutionalise good practices.
Despite the widespread application of quality improvement approaches in health-care applied in low-resource settings, relatively little rigorous evidence is available on their effectiveness in those settings. Yet systematic evaluations suggest that standards-based interventions can improve provider performance and the quality of care in developing countries, especially when skill levels are low to start with (Wagaarachchi et al., 2001, Jamtvedt et al., 2006, Bailey et al., 2010). For example, criteria-based audit, which assesses clinical practices against best practice guidelines, has been successfully used to improve the management of postpartum haemorrhage and woman-friendly maternity care at dozens of health centres in Malawi (Kongnyuy et al., 2009a, Kongnyuy et al., 2009b).
To add to this evidence base and provide insights for scaling up the PQI process in Malawi, an evaluation of the PQI RH intervention was conducted in 2009. The objective was to determine the intervention's impact on the quality of care and reproductive health outcomes. At the time of the evaluation, no facilities had yet reached the recognition stage of the PQI process.
Study hypotheses were as follows:
- 1.
Facility readiness for reproductive health services, in terms of supplies, equipment, and infrastructure, is better at intervention facilities than comparison facilities.
- 2.
Observed quality of antenatal care (ANC), family planning (FP), labour and delivery (L&D), and postnatal care (PNC) is better at intervention facilities than comparison facilities.
- 3.
Reproductive health outcomes are better at intervention facilities than comparison facilities.
Section snippets
Design
The evaluation employed two designs. Firstly, a post-only quasi-experimental design compared observed service quality at facilities that had implemented the PQI RH intervention (intervention group) with facilities that had not yet implemented the intervention (comparison group). Secondly, a time-series analysis of service statistics examined trends in delivery care, such as the provision of caesarean sections and the use of partographs, and service utilisation at intervention and comparison
Description of participants
Interviews and observations were conducted with 98 providers, equally divided between intervention and comparison facilities. There were no significant differences in sex, age, cadre, and work experience between the study groups (Table 1).
At each facility, a minimum of two client–provider interactions were observed in each service area; a few additional observations of L&D and PNC services were made at some hospitals. A total of 139 interactions were observed: 68 at comparison facilities and 71
Discussion
Although quality of care was high at comparison as well as intervention facilities, the evaluation found that the PQI intervention significantly improved the management of PNC and FP clients. These findings are supported by other evaluation studies showing a positive impact of quality improvement interventions on providers' compliance with clinical standards (Hermida and Robalino, 2002) and on provider performance in service delivery (Luoma et al., 2000, Bradley et al., 2002, Lande, 2002).
Conclusion
The PQI process has proven effective in improving the quality of care of reproductive health services in a low-resource setting. Since providers at both intervention and comparison facilities may have been influenced by the Hawthorne effect, observed quality of care may have been better than the norm. However it is unlikely that observed differences between the two groups in quality of care scores were due to this effect since both sets of providers would likely have been affected in the same
Acknowledgements
The authors would like to thank their colleagues and partners including the Ministry of Health Reproductive Health Unit, Directorate of Nursing, Quality Assurance Technical Working Group, and United States Agency for International Development (USAID), who contributed to this national evaluation and who, since 2001, have facilitated the design and national roll-out of the PQI RH intervention in Malawi. We also thank the providers and clients who allowed our study team to observe and interview
References (28)
- et al.
Participatory evaluation of reproductive health care quality in developing countries
Social Science and Medicine
(2002) - et al.
Strategies for reducing maternal mortality: getting on with what works
Lancet
(2006) - et al.
Evidence-based, cost-effective interventions: how many newborn babies can we save?
Lancet
(2005) - et al.
Emergency obstetric care: how do we stand in Malawi?
International Journal of Gynecology and Obstetrics
(2008) Tackling Malawi's Human Resources Crisis
Reproductive Health Matters
(2006)- et al.
How can we achieve and maintain high-quality performance of health workers in low-resource settings?
Lancet
(2005) - et al.
Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries
International Journal of Gynecology and Obstetrics
(2001) Human Resources for Health Country Profile: Malawi
(2009)- et al.
Promoting accountability in obstetric care: use of criteria-based audit in Viet Nam
Global Public Health
(2010) - et al.
Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system
Human Resources for Health
(2009)
Human resources for maternal health: multi-purpose or specialists?
Human Resources for Health
Increasing compliance with maternal and child care quality standards in Ecuador
International Journal for Quality in Health Care
Audit and feedback: effects on professional practice and health care outcomes
Cochrane Database Systematic Review
Using criteria-based audit to improve the management of postpartum haemorrhage in resource limited countries: a case study of Malawi
Maternal and Child Health Journal
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