Closing the quality gap : investigating health system bottlenecks and quality improvement strategies for maternal and newborn care in Sub Saharan Africa, focusing on Tanzania

摘要

BACKGROUND: Despite substantial gains in survival in the past three decades, around 200,000maternal deaths, 1 million newborn deaths and 1 million stillbirths occur annually in Sub SaharanAfrica (SSA). The majority of these could be averted by effective medical interventions, butimplementation in the context of under-resourced health systems is a challenge. The content of carereceived by mothers and newborns is therefore often of poor quality and the discordance betweenincreased utilisation of care without the expected corresponding gains in survival is referred to asthe quality gap. Closing this quality gap demands an understanding of its underlying determinants,approaches to measure its characteristics and effective improvement strategies.AIM: To assess implementation bottlenecks in district health systems, and evaluate strategies toaddress these, in order to contribute to closing the quality gap in maternal and newborn care in SubSaharan AfricaMETHODS: Study I was a multiple case study comparing attributes related to use of ClinicalPractice Guidelines (CPGs) for maternal health in Burkina Faso, Ghana and Tanzania, focusing ontheir content and format, using document review and key informant interviews. Study II was across-sectional study where household and health facility data was linked to estimate effectivecoverage, the extent to which interventions were implemented as intended, of five key maternal andnewborn health interventions, and to identify bottlenecks in their implementation in rural Tanzania.Study III was a qualitative study using a grounded theory approach to analyse 17 health workerinterviews, examining the underlying conditions for care provision and health workers’ perceptionsof what constitutes quality of care (QoC). Study IV was a qualitative process evaluation of acollaborative quality improvement (QI) intervention in rural Tanzanian health facilities. Healthworkers’ perceptions of the components of the intervention was analysed through a deductivetheory driven approach, utilising the i-PARIHS framework as a lens, to elucidate contributors tomechanisms of effect.RESULTS: While the content of national CPGs correlated well with WHO guidelines, deficienciesin their format in terms of usability and applicability may limit implementation by health workers inpractice (Study I). Effective coverage of maternal and newborn health interventions varied between3% and 49% in the target populations despite high utilisation of health services; the implementationbottlenecks being similar within, but different between, districts (Study II). Unpredictability wasidentified as the fundamental condition for maternal and newborn care provision and an importantdeterminant of quality (Study III). The components of collaborative QI interpreted as contributingto mechanisms of effect were: (1) improvement topics with a high degree of fit with existingpractice; (2) run-charts using local data to monitor progress; (3) mentoring and coaching inindividual health facilities. (Study IV).CONCLUSIONS: Improving the format of CPGs for maternal and newborn care could increasetheir usability and applicability, and therefore implementation, by health workers in practice (StudyI). Estimating effective coverage in conditional stages along an implementation pathway can help toidentify bottlenecks within health systems. Differences between districts reveal the utility ofanalysing bottlenecks at this level (Study II). Increasing predictability of health facility readiness,and focusing on the experiences of health workers, should be prioritised in order to improve QoC(Study III). Focusing on intervention components which meet the perceived needs of healthworkers may enhance mechanisms of effect and result in greater improvements in QoC and couldalso be used to guide harmonisation between different QI approaches (Study IV).