Engaging Users for Quality Enhancement and Rights (EU QUERO):Strengthening the maternal and child healthcare system over the first 1000 days in Brazil

The quality of healthcare available to women and children within the first 1000 days of life (from conception until about 2 years of age) in Brazil is highly variable, despite policies for improvement. This has led to higher maternal mortality and morbidity than may be expected in a country such as Brazil. This project, EU QUERO (meaning 'I want' in Portuguese), is testing whether an intervention to improve the quality of care is feasible to conduct as well as indicating whether it is likely to be successful. This will be conducted in two states of Brazil, Goiás and Maranhão, both of which have poorer maternal health than expected.

Prior to the intervention, a period of assessment of current quality will be conducted using two datasets that have already been collected. Results from this analysis will be mapped using the latest techniques so that hotspots of good or bad quality healthcare can be identified. This will inform the areas selected for the intervention.

The EU QUERO intervention is implemented within Basic Health Units (the smallest level of the health system organisation) and encompasses two different elements. The first is to make mothers and the wider community more aware of the current quality of care available to them at different points within the first 1000 days of life - during pregnancy, during delivery, in the immediate post-delivery period and with regard to the child's health. This will be conducted by the development of facility level quality scorecards which will highlight the good and poor aspects of healthcare to users. The scorecards will list the four different phases within the 1000 days and rate the services available to the mother within each phases, with the best quality services receiving a 'Diamond' rating, while the poorest will receive a 'Bronze' rating. Previous research indicates that knowledge of these aspects improves quality through greater transparency of the health system, while health workers also understand the aspects where they are not performing and make a concerted effort to improve.

The second element of the intervention is through the delivery of rights-based education to mothers. This will include knowledge about individual rights to health care, including highlighting what an individual should be entitled to and the quality that should be expected. This has been seen to empower mothers who will then be encouraged to demand more of the health providers, again improving quality of care.

EU QUERO will develop these scorecards and rights based education materials to disseminate within selected Basic Health Units and, following this happening, assess if this is a feasible intervention to conduct at a wider scale. Improvements in quality will be assessed through the development of new quality scorecards, which will indicate what has been improved and whether any improvements have occurred evenly over the 1000 days period under study. Quality will also be assessed through looking at health outcomes, such as whether mothers received adequate antenatal care or whether the child received vaccinations in a timely fashion. A further aspect is an explicit focus on ensuring that adolescent voices are heard throughout the intervention and evaluation.

The project is conducted in collaboration with the state Ministries of Health and hence the successful implementation of the intervention will inform future strategies to improve healthcare for mothers and children. It will also engage mothers, communities, health workers and policymakers throughout the period of implementation, with the actual intervention co-created between the project team and these stakeholders, so the material presented to mothers is relevant and understandable. The intervention will be assessed for scalability within Brazil and in other countries, with mothers facilitated to demand the best quality care available, strengthening the health system as it responds to these demands.

Maternal and child health care in Brazil is highly variable in quality and reach, both within and between states. Brazil as a nation, including the two states of Goiás and Maranhão, both failed to achieve the MDG on maternal health. Community engagement in the health system, as well as greater knowledge of rights to healthcare, are both known, with varying levels of evidence, to improve quality of care. A small number of studies have demonstrated this for maternal and child healthcare in South Asia and sub-Saharan Africa, while evidence in Latin America is scarce. Little knowledge exists concerning whether interventions targeting engagement and rights are feasible within the Brazilian context.

EU QUERO is a feasibility study for an intervention to improve the quality of health care received by mothers and children in the first 1000 days of life in two states of Brazil. The research has three main steps:

(1) the development of facility level scorecards and a mapping of quality of care for mothers and children within the two states using existing data. This will be of use in itself, while also being used in the following intervention.

(2) the implementation of an intervention, facilitated by community health agents within Basic Health Units (BHU), to improve knowledge of rights amongst women and the wider community. The intervention will also disseminate scorecards in order that the women are fully knowledgeable about the service quality. The intervention will also target the health workers within the BHU itself.

(3) an investigation into the pathways through which increased knowledge about quality and rights actually feeds through into improved service quality. These pathways are not currently understood.

Results of EU QUERO will indicate whether and how to roll out at scale and also enhance our understanding of community accountability as a tool to improve the quality of services offered by health systems at local level.

The ultimate impact of EU QUERO will be to improve access to, and utilisation of, appropriate and high quality services for mothers and children during the first 1000 days of life, with a focus on adolescent mothers. It will directly seek to do so by strengthening accountability and quality of the health system provided to mothers and children during the 1000 days from conception to second birthday. Improved quality of healthcare will feed through into reduced maternal and child mortality and morbidity, as well as greater proportions of individuals receiving the care that they need and deserve. The project is to assess the feasibility of an intervention to improve the quality of care given; if successful a full trial is planned, which will reach a wider number of beneficiaries and will maximise its impacts.

Within this feasibility study there are a number of direct beneficiaries based on the planned activities within the two Brazilian states, Goiás and Maranhão.

Mothers and children within the intervention areas will benefit from the increased knowledge of their rights for healthcare and will develop skills to demand better quality healthcare. This group will also have information on the quality of services available to them, both at the start and end of the intervention and can use this to enhance the levels of care available to themselves.

Adolescent mothers make up a sizeable proportion of all mothers within the two states. This project will highlight this group separately where possible, developing separate quality scorecards and data collection mechanisms. This will highlight the importance of having a focus on this group and allow specific policies to be targeted, further improving the quality of services received by them.

Policymakers at both the state and national level will use the map of quality within each state to identify priorities for enhanced support or beacons of excellence. This information will be developed in the first year of the project, allowing strategies to be enacted quickly and simply, enhancing the health of all those within the two states.

International organisations who are involved in improving maternal and child health (e.g. the World Health Organisation, the World Bank, Pan-American Health Organisation, Inter-American Development Bank, United Nations Population Fund, and the United Nations Development Programme) will be able to use the results of the study to recommend interventions in other countries, which will benefit women around the world.

Fellow researchers in a wide variety of disciplines will benefit through the publication of academic journal articles and conference presentations.

The partnership between Brazilian and UK universities is equal and has mutual benefits through the enhancement of capacity. This will be sustainable through co-working, formal training, workshops and mobility between institutions. This will produce lasting benefits for both partner institutions and individual researchers. Enhanced capacity can be used to initiate and evaluate further interventions that will improve the health of the Brazilian population.

The project will tackle maternal and child health within Brazil. Poor health within this population group is seen in many low and middle income countries on the DAC list, with many strategies designed to improve healthcare. The quality of maternal health care is known to be a major cause of high mortality and morbidity worldwide, as simply receiving a health service does not make it a good quality health service. This intervention therefore tackles the next stage of the drive to improve maternal health by improving the quality of services offered, especially for marginalised groups. This is a worldwide problem in low and middle-income countries, and hence the results from this study will be applicable in a wide range of contexts and countries.