Stakeholder monitoring to improve quality of MNH care in public and private sector facilities following a district health systems approach

Improving the quality of care is emphasized in maternal and neonatal health (MNH) to enhance efficacy and effectiveness of interventions. However, there is neither any globally accepted definition, nor any standardized tool to monitor quality of care in MNH. Bangladesh is on-track in achieving the targets for Millennium Development Goal 4 & 5 with low institutional delivery rate (29%), the majority (18%) of which takes place in for-profit private sector facilities. Poor quality of care in public facilities compels pregnant women to use private facilities which may lead to catastrophic health expenditure. Users may perceive services from private sector facilities to be superior to services from public facilities due to incentive mechanism. The unregulated private sector is growing fast in the country and there are reports of overcharging and unnecessary caesarean sections in the private facilities. Dual practice is common among public sector providers and referral from public to private for financial benefit is not uncommon. Governance is weak to oversee the pluralistic health system where the private sector is increasingly contributing in the health care delivery. Innovative systems' approach needed for better integration of private sector inputs to maximize their contribution in achieving the national public health goals.
Audit and feedback has demonstrated its feasibility and effectiveness in improving providers performances in clinical settings in high-income countries. Several global programs such as JHPIEGO (Johns Hopkins Program for International Education in Gynecology and Obstetrics) and AMDD (Averting Maternal Death and Disability) of the Columbia University have developed tools to monitor and improve quality of MNH care. In this study we plan to review the existing audit and quality improvement tools to adapt them in Bangladesh to test its feasibility, acceptability and effectiveness in improving quality of MNH care following a district health systems approach. The study will be conducted in a medium performing district of Bangladesh following a mixed method, pretest-post-test research design .The tools developed, will be contextualized through multiple stakeholders consultations and finalized after pretesting in a hypothetical field outside the study district. A baseline study will be conducted for needs assessment and benchmarking the quality indicators in public and private sector hospitals for future evaluations. Baseline study will include SWOT and Stakeholders Analysis to understand the context and building broader alliance to facilitate the implementation of the designed interventions. District Quality Assurance (QA) Team will be formed involving key stakeholders in the district, including the users. Developed monitoring and feedback tool will include key quality indicators covering structure, process and outcome dimensions of quality of care and will be implemented through joint quarterly visit of all public and private facilities by the district QA team members. Feedback will be given every 6 monthly through workshops and periodic quality monitoring reports. Process documentation will be the key method for evaluation. Qualitative Key Informants Interviews with explore the enabling and constraining factors impacting both implementation and making changes in quality of MNH care. The quantitative pre and post intervention surveys will be the other methods for assessing the change in quality of care (both technical and perceived) due to introduction of stakeholders' monitoring and feedback. A costing exercise will measure the cost of interventions to inform policy for scale-up and sustainability. Study outcome will be communicated to target audience using multiple channels such as journal articles, conference abstracts, policy briefs and newspaper articles. An implementation research protocol will be developed to inform policy for future scale-up nationwide to impact maternal and neonatal health outcomes.

The present study aims to develop a 'stakeholders' monitoring tool' to test its feasibility, acceptability and effectiveness in improving quality of MNH care following a district health systems approach. Existing global tools on 'audit and feedback' will be reviewed and adapted through stakeholders' consultations. Quality Assurance (QA) team will be formed involving key stakeholders in the district and a quality monitoring cell will be established within the premises of the district health office. Baseline study will include SWOT, stakeholders' analysis and facility survey for needs assessment and benchmarking quality indicators for future evaluations. Technical and social mobilization training will be organized to facilitate the audit and feedback process. The district QA Team members will monitor all public and private facilities quarterly using the developed tool. Feedback will be given every 6 monthly through monitoring reports and stakeholders' workshops. Process documentation will be key method for evaluation. Key Informants Interviews (KII) will be conducted throughout the study which will provide information about existing situation, barriers, facilitators and feasibility and sustainability of the tool. In addition, observations will be made during implementation of the tool which will facilitate understanding the interactions of care and the social context of implementation. All interviews will be recorded and data transcription will be immediate. Data analysis will involve reading transcripts repeatedly to find emerging themes. Transcripts will be reviewed carefully and summaries will be prepared and coding will be done by using Atlas-ti. Other methods will include quantitative pre and post-intervention facility survey along with review of delivery records to assess the impact in terms of improving quality. Sample size will be adequate to detect a 20% improvement. A summary quality index will be computed and compared to assess the impact of intervention.

The proposed research will impact different group of beneficiaries. The 1st group of beneficiaries will be the health policy and systems managers of the ministry of health and family welfare. Throughout the implementation of the study, the MOH will be integral and that will ensure ownership of the innovative approach by the government. A monitoring framework will be available for the health systems managers to oversee the complex and pluralistic health systems where for-profit private sector is a dominant caregiver. The second group of stakeholders are the service providers and owners who will benefit from this research. The 3rd groups of beneficiaries are the users of MNH care services while the last group are the academic beneficiaries.
A comprehensive communication strategy will be undertaken to maximize the benefit out of the research. Throughout implementation, feed back will be given to the participating organizations and respective government departments and local government authorities that will enhance responsiveness of the service providers and capacity of the health systems managers. Extensive communication using multiple channels will attract the government and other stakeholders to broaden the scope for more benefit by the people through scaling-up. An implementation research protocol will be developed and implemented in collaboration with the respective government departments where both researchers and policy program managers will work together to facilitate the approach of scaling-up nationally, if successful. The study findings will be communicated to larger scientific community through journal articles and conference abstracts for developing similar programs in low income countries where health system constrained to ensure good governance for better health outcomes.