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

Lead Research Organisation: ICDDRB
Department Name: Maternal and Child Health Division

Abstract

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.

Technical Summary

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.

Planned Impact

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.
 
Description We categorized our study health facilities into intervention and control group. Following up the effect of study interventions were measured through separate survey during baseline and endline. Sustained improvement among intervention health facilities were apparent. Some structural elements were difficult to address e.g., human resource and out-house hospital waste management. Quality improvement has observed in Medical record-keeping and In-house waste management . Higher baseline QoC and more improvement apparent in larger facilities. The cost analysis data shows once the start up cost has been covered, continuous supportive supervision requires minimum cost. The precise result in certain quality indicators are given below
• Nearly 100% had registration but 20-30% did not have updated registration, during endline percentages improve both side,
• Service price and service location board were displayed only 20-30% hospital, increased to >70% separate labour room was not present in about 40 % health facility that reached to 80%
• emergency room was not sign posted in 60% facilities that increased to more than 80%
• 24 hrs electricity & running water was not a problem, as well the cleanliness .
• BCC materials were present <20% and reach >80%
• comments box availability increased to over 70% to >80% from 30-40% reported during baseline
• <20% had separate register for IPD/OPD/OT increased to over 40%.
• Standard operating procedures for clinical management were nearly absent which increased to 70%
• Increased the availability of three separate color coded bin for waste segregation and disposal to 80% from baseline rate of <20%
• cholorine solution with in labour room and OT as disinfectant has also increased but out house WM situation does not improve much
Exploitation Route Further Implementation researches are necessary necessary with intervention scale-up to see the validity of our preliminary findings. this can also help to understand the context specific challenges and facilitating factors in other districts of Bangladesh. in doing so Phase-wise approach is preferred
Sectors Healthcare

 
Description this is the first research being done in the for profit private sectors in Bangladesh. The autonomous nature of this sector have been considered as main hindrance to bring them under any quality improvement framework . However, we could rightly prove that once the private clinic owners could convinced that improving quality does not conflict with their financial motive rather ensure the care given by them is safe and effective they are willing to participate in any such Quality improvement initiatives. The quality improvement secreteriat of Government of Bangladesh was pretty much engaged with our project. They got practical experiences that punitive approach does not work in this sector rather periodic supportive supervision with set check list could give them clear instruction what to do and how to measure the progress. we are communicating with national level policy planner and donor agency for further fund acquisition to test the validity of our preliminary findings in other settings before further amendment in related policies.
First Year Of Impact 2016
Sector Healthcare
Impact Types Policy & public services

 
Description A health dialogue at national level in Bangldesh
Geographic Reach National 
Policy Influence Type Participation in a national consultation
Impact To undertake policy analysis on emerging health issues in Bangladesh and promote discussions on evidence-informed health policy process for improved health outcomes, a Health Policy Dialogue titled "Engaging Private Sector to Achieve Universal Health Coverage in Bangladesh", took place on 28 April 2018, at the CIRDAP Auditorium, Chameli House, Topkhana road, Dhaka.This Health Policy Dialogue was organized by the European Union Supported Strengthening Health, Applying Research Evidence (SHARE) project of icddr,b. The objective of this dialogue was to identify policy challenges in the private health sector in Bangladesh, explore practical solutions and attribute to developing policy recommendations for future implementation. Health Policy Dialogue- a Think Tank group involving eminent scientists, academics, development thinkers and civil society members, who have expertise and knowledge in the area of public health, human rights and development issues in Bangladesh was launched in 2017. This Think Tank was engaged in providing policy advice, conducting policy dialogue and commissioning relevant research issues. In order to create supportive policy environment and facilitate trust between mass people and health service providers, this Think Tank is expected to work as platform for bringing together national health experts, policy makers and citizens.
URL https://europa.eu/capacity4dev/capacity-building-in-public-health-for-development/discussions/share-...
 
Title Facility survey tool 
Description Facility survey tool/ questionnaire is used to capture structural quality of health facilities i.e. infrastructures, facilities and equipment. 
Type Of Material Physiological assessment or outcome measure 
Provided To Others? No  
Impact Using the tool, we were able to collect information regarding structural quality of health facilities that are included in the study to be used as baseline to see any improvement at the end of the study. 
 
Title Qualitative guidelines 
Description The guidelines are used to capture qualitative data on the feasibility, acceptability and effectiveness of the participatory stakeholder monitoring and feedback approach used in the current study 
Type Of Material Physiological assessment or outcome measure 
Provided To Others? No  
Impact Using the guidelines we were able to obtain qualitative data on the feasibility and acceptability of the approach that we use in the study. 
 
Title Quality monitoring score card 
Description This tool has been used as an intervention tool for this project. The District Quality Improvement Committee is using this score card to mark the quality of services during their routine monitoring and feedback visit at the targeted intervention health facilities. The score card is capturing both the structural and technical aspects of quality of care. 
Type Of Material Physiological assessment or outcome measure 
Provided To Others? No  
Impact The research team could able to implement this tool for 2 times so far. It has been noticed that this tool is very effective to guide the Quality monitoring team to keep focus while doing the quality monitoring visit. since the tool is tab based the summary score can be used on instant manner to give the feed back to the visiting facility. This instant feedback is found effective since the subsequent visit has reported 5-10% improvement in the quality of services observed 
 
Title Record review tool 
Description Record review tool/ questionnaire is used to capture the quality of healthcare practices as recorded in the medical records. 
Type Of Material Physiological assessment or outcome measure 
Provided To Others? No  
Impact Using this tool, we were able to obtain data on MNH practices by health workers of the included hospital. We were also able to assess the quality of medical records in these hospitals. 
 
Title 6 quality monitring score cards data base 
Description This data base has been generated from periodic quality monitoring visit score. data collected through tab and transferred to STATA for analysis 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact This tab based data entry was useful to generate report and provide feedback to respective health facility instantly during visit period. 
 
Title Baseline Facility survey data from private for profit helath facilities 
Description This data set has the 34 health facility survey and 1343 inpatient medical record findings 
Type Of Material Database/Collection of data 
Year Produced 2015 
Provided To Others? No  
Impact Baseline findings of this study would be the 1st step in Bangladesh which are exploring the quality of MNH care in Private for profit health facilities 
 
Title End line facility survey data 
Description End line facility survey & required record reviews from all the study health facilities (34) have recently been finished(6.2.17) 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact not yet. as still it is in the raw format 
 
Description Additional funding from DfID Bangladesh 
Organisation Government of the UK
Department Department for International Development (DfID)
Country United Kingdom 
Sector Public 
PI Contribution icddr,b provides the technical expertise in implementing the study to test the feasibility, acceptability and effectiveness of a participatory stakeholder monitoring and feedback approach in improving the quality of maternal and neonatal health (MNH) care in district level health facilities in Sylhet
Collaborator Contribution DfID Bangladesh partly funds the implementation research to test the feasibility, acceptability and effectiveness of a participatory stakeholder monitoring and feedback approach in improving the quality of maternal and neonatal health (MNH) care in district level health facilities in Sylhet
Impact - Research protocol - Data collection tool to collect quality indicators (facility survey and record review) - Guidelines to obtain qualitative data on feasibility, acceptability and effectiveness of a participatory stakeholder monitoring and feedback approach - Quality monitoring scorecard - Quality indicators data
Start Year 2015
 
Description MOU (Memorandum Of Understanding) with Quality Improvement Secretariat of Ministry of Health and Family welfare,Bangladesh 
Organisation Ministry of Health and Family Welfare
Country Bangladesh 
Sector Public 
PI Contribution icddr,b provides technical expertise and logistic support to ensure smooth implementation and evaluation of the Quality Monitoring and Feedback approach to improve quality of maternal and neonatal care in district level health facilities in Sylhet.
Collaborator Contribution Quality Improvement Secretariat (QIS), housed at the Health Economic Unit of Directorate General of Health Services serves as our partner in implementing Quality Monitoring and Feedback approach. The Quality Improvement Committee (QIC) responsible for the regular monitoring and feedback visit to health facilities was formed in Sylhet as the extension of QIS at district level.
Impact - Quality monitoring scorecard - Quality monitoring data from intervention health facilities
Start Year 2015
 
Title Quality monitoring score card 
Description Tab based quality monitoring score card which has generated under this research activity was reported as user friendly and effective on engaging key stakeholders on quality improvement initiative. The indicators used to measure the quality of MNH care were derived from standard hospital assessment checklist proposed by different international organization (WHO, UNICEF). The baseline study findings were further helpful to set the bench mark for periodic monitoring. The respected QIC members, district level health managers, clinical practitioner and civil society representatives have also mentioned that the tool contained all the basis and essential quality indicators which were easy to follow up. summary score coming at the end of visit was helpful to provide feedback instantly to the respective health facilities. Moreover, there was option to compare the previous round visit and to report on the improvement 
Type Products with applications outside of medicine
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2016
Development Status Actively seeking support
Impact This tab based score card was much useful to engage the comparatively busy QIC members 
 
Title Facility survey and Record review tools 
Description The software is developed to digitally capture the data obtained from facility survey and records review 
Type Of Technology Software 
Year Produced 2015 
Impact Using the software we make the data more easily captured and more readily put into database for analysis 
 
Title quality monitoring score card 
Description An Android application has been developed for Quality Monitoring Score Card.Quality indicators were set based on the baseline quantitative finding and also from the recommendation taken from quality experts. Based on the weight this app provided facility level score instantly once the data has been entered during periodic quality monitoring visit.The app was designed such a way that off line data collection was possible and multiple visit's information could be stored. data could also be exported in STATA format for further analysis 
Type Of Technology Webtool/Application 
Year Produced 2016 
Impact Using this software, the visiting quality improvement committee could provide instant feedback to the visiting health facilities and could compare the level of improvement. the trend data shows the clear evidence of quality improvement on the selected indicators 
 
Description Disseminate baseline study findings in a workshop in NIPSOM "Private scetors in Health" 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Postgraduate students
Results and Impact NIPSOM , the post graduate institute of public health has invited us to participate in a plenary session on "Private sector in Health in Bangladesh". Dr. Iqbal, Sadika Akhter, Dr. Tahmina and Rushdia Ahmed working for MRC funded project had participated in that session and present baseline study findings from this research project
Year(s) Of Engagement Activity 2016
 
Description An end line study dissemination workshop was organised at the study site, Sylhet with the participation of all the private clinic owners , key stakeholders from local and national level 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Study participants or study members
Results and Impact This workshop was planned to disseminate study findings among the all study participants. Representatives from all the 34 study health facilities were attended there. in addition to that key stakeholders from both public and private health sectors were attended to evaluate study findings. All the participants agreed that this innovative approach should continue even after phase out of the of the project as it could substantiated quality improvement in some major areas . A positive competitive attitude has developed among all the study health facilities to perform better with the set target to be achieved. The government authority also mentioned that the HR and logistic capacity of the district health authority is not comprehensive enough to monitor the ever growing private sector on routinely basis. In this regard having a quality improvement committee with the active participation of different level key personal could be an better option to engage the private sector in their own quality improvement initiative through much supportive way
Year(s) Of Engagement Activity 2017
 
Description Baseline dissemination workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact The meeting was held to share the findings on quality MNH care from baseline to all stakeholders. The sharing has enlightened the audience regarding the status of quality MNH care in hospitals in Sylhet.
Year(s) Of Engagement Activity 2016
 
Description Consultation meetings 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The meetings were held to consult with obstetric and gynecology experts as well as doctors working in different levels of public hospitals regarding the tools for facility survey and record review that would be used in the study to capture quality in MNH care in the baseline and endline. The experts commented on the components/questions in the tools regarding their appropriateness and usefulness, as well as suggested different components that need to be taken out or added, which lead to the finalization of the tools.
Year(s) Of Engagement Activity 2015
 
Description Consultation meetings 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The meeting was held to consult with obstetric and gynecology experts as well as doctors working in different levels of public hospitals regarding the Quality monitoring scorecard that would be used in the study to regularly monitor and give feedback to health facilities. The experts commented on the components/questions in the scorecard regarding their appropriateness and usefulness, as well as suggested different components that need to be taken out or added, which lead to the finalization of the scorecard.
Year(s) Of Engagement Activity 2015
 
Description Dr. Iqbal Anwar, Dr. Allayne adams and Dr. Tahmina Begum became memeber of the private sector working group for the health system global symposium(HSG). The HSG symposium is scheduled biennually engaging more than thousand delegates or health system expert across the world 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Being the member of private sector working group, the listed investigators get chance to subscribe for regular newsletter, receiving invitation to take part for technical meeting at international level. This networking seems much beneficial to build networking with donors who are interested to invest on private sector health research
Year(s) Of Engagement Activity 2018
 
Description Initial meeting with Quality Improvement Secretariat (QIS) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The meeting was held to introduce to Quality Improvement Secretariat (QIS) of Directorate General of Health Services regarding the study and its objective to test quality improvement initiative in district level health facilities, and to initiate collaboration with QIS to implement the study. The meeting resulted in the interest expressed by QIS to collaborate in the study and to have a formal MOU with icddr,b.
Year(s) Of Engagement Activity 2015
 
Description Mid term dissemination workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact It has been scheduled to conduct 6 quality monitoring visit with in the18 months of intervention phase of the study. Each health facility has received instant feedback from the visiting quality improvement committee based on their achieved score on listed quality indicators. At the middle of intervention phase, one workshop was organized to disseminate the findings among all key stakeholders maintaining anonymity. The three best performing health facilities were being awarded through this workshop.The main objective was to enhance positive competition among participating health facilities.
Year(s) Of Engagement Activity 2016
 
Description Participate in 5th Health System Researh Symposium in Liverpool on October 2018 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The investigators team has organized a plenary session at the prestigious conference on the 5th HSR symposium. The study investigators, representative from the ministry of health Bangladesh and private clinic owner association of Bangladesh present their own perspective from the recently finished private sector project from urban Bangladesh, funded by MRC,UK.
Year(s) Of Engagement Activity 2018
URL http://healthsystemsresearch.org/hsr2018/wp-content/uploads/2018/09/HSR2018-Program.pdf
 
Description Preliminary stakeholders meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact The meeting was held to introduce local stakeholders (district health officials, clinic owners, obstetrics and gynecology experts, representative from Bangladesh Medical Association, and representative from Private Clinic Association) to the study and its objective and to initiate collaboration and engagement of all stakeholders. The meeting resulted in the interest expressed by stakeholders to be actively involved and engaged in the study.
Year(s) Of Engagement Activity 2015
 
Description QIC formation meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact The meeting was held with key stakeholders from Sylhet to form Quality Improvement Committee (QIC) who would be responsible for routine quality monitoring and feedback visit to the intervention hospitals. The meeting was resulted in the formation of QIC with members comprising of deputy civil surgeon, some obstetric and gynecology experts, and some other district health officials.
Year(s) Of Engagement Activity 2015
 
Description QIC meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact The meeting was held to discuss the Terms of Reference for the QIC members as well as to introduce to them the Quality monitoring scorecard that would be used for the monitoring and feedback purpose. The QIC members understood the TOR and were acquainted with the Quality monitoring scorecard, and plans were made for the monitoring and feedback activities.
Year(s) Of Engagement Activity 2015
 
Description Quality Improvemnet Commitee (QIC) meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact This was the regular meeting of QIC. All the QIC members, relevant policy planners and representative from project partner namely QIS, MOHFW were present at that meeting
Year(s) Of Engagement Activity 2016
 
Description Quality monitoring scorecard training 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact The meeting was held to train QIC members on the use of the Quality monitoring scorecard. QIC members understood the components and the contents of the scorecard
Year(s) Of Engagement Activity 2015
 
Description Stakeholder workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Industry/Business
Results and Impact The meeting was held to introduce to the wider local stakeholders in Sylhet, especially - but not limited to clinic owners regarding the study and its aim to facilitate improvement in MNH care in district level hospitals. The meeting resulted in the interest expressed by stakeholders to be actively involved and engaged in the study.
Year(s) Of Engagement Activity 2015
 
Description Training on waste management and record keeping 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact The study has identified waste management and record keeping as major drawbacks in the quality of MNH care among hospitals in Sylhet. To address this, a training on waste management and record keeping was held for hospital managers and staff responsible for waste management and record keeping. The participants reported that they knew better about the issues and express willingness to change the way the two things have been practiced.
Year(s) Of Engagement Activity 2016