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Maternal, Newborn and Child Health

Developing clear expectations and objectives for health workers focusing on MCH in Niger

Improvement Report
Author(s): 
Maina Boucar, Alison Wittcoff
The Report
Problem: 

In Niger’s Tahoua region, the challenge of finding enough human resources is severe. 2008 data compiled by the Ministry of Health show the ratio of doctors to patients is 1 per 100,000, there is 1 midwife per 9,000 women of child-bearing age, and 1 nurse per 8,000 people in the general population. These ratios are even higher in rural zones, where more than 80% of Tahoua’s population lives. This situation is aggravated by frequent reassignment of staff, as well as weak supervision of and in-service training for health workers. In response to this human resource challenge, the Government of Niger requested the assistance of the USAID Health Care Improvement Project to build the capacity of the Ministry of Health in managing and supporting health care workers in the Tahoua Region. For the first time, the collaborative approach was applied to managing health workers and linking improvements in performance management with impact on the quality of care for patients. The primary goal of the human resource improvement collaborative is to improve health worker performance (productivity and engagement) and the quality of maternal care by building the capacity of local management to sustain improvements in Niger’s Tahoua region. The pilot phase of the Niger Human Resource Collaborative includes 15 facilities from all eight Tahoua districts. The collaborative also uses15 clinical QI teams working on human resource and clinical indicators, as well as 11 management QI teams focusing on human resource indicators. At the facility level, the quality improvement team includes the facility manager, providers, a union member, and a district health team member. Seven improvement objectives were defined for the Human Resource Collaborative that will be introduced to teams in phases, beginning with work on the first objective. The seven objectives are: 1. Clear expectations and objectives for health workers 2. Competency development 3. Frequent feedback 4. Fair evaluation 5. Reward and consequence 6. Professional advancement 7. Safe and adequate environment

Intervention: 

In May 2009, teams were introduced to Objective #1: defining objectives and clear expectations for all staff during the first learning session. Teams were shown how to articulate and align goals, design job descriptions with performance objectives, and develop action plans to define and align goals and objectives for all health workers within their facilities. At the second Learning Session, teams shared their work with respect to Improvement Objective #1, including the challenges and successes of aligning and rationalizing their jobs with Ministry priorities. They also prioritized goals that would measure their progress in key areas that would address the first objective. The 15 clinical quality improvement teams selected both human resource and clinical objectives to measure their results. Clinical objectives included increasing the rate for assisted deliveries, reducing rates and improving management of postpartum hemorrhaging, and increasing family planning coverage in health facilities.

Results: 

A key to Objective #1’s outcome was having quality improvement teams develop written job descriptions with clearly defined tasks for health workers in their ward. The number of written job descriptions for health workers steadily increased at all 25 sites since teams began working on the first objective. As of January 2010, 65% of health workers have a written job description. Teams are now working on developing job descriptions for auxiliary workers. The human resource collaborative has also illustrated the link between human resource inputs and quality of care outcomes. Through improving human resource systems and processes, clinical indicators are positively impacted and the quality of care delivered is improved. For example, now that health workers have clearly defined tasks, they are able to concentrate their efforts on the key tasks and priorities of their position, which allows them to use their time more effectively. As of December 2009, the percentage of deliveries performed at facilities has increased since the start of the collaborative from 23% to 28%. As of November 2009, sites had reached a level of compliance with active management of the third stage of labor standards of 90%. There also has been an encouraging downward trend in postpartum hemorrhage rates sites are experiencing as a positive effect of the collaborative. The postpartum hemorrhage rate was 0% in December 2009. Teams measured the effect of their interventions by collecting data on both clinical and human resource indicators and documenting their work using the Standard Evaluation System database and journals. Examples of successful changes tested by teams relating to Objective #1 includes: 1. Maternity: Transferred prenatal consultation, which used to be done at the maternity, to the health center to reduce congestion and waiting time at the maternity. 2. District hospital: Transferred family planning activities to a midwife instead of the cashier. The team realized it was important to have a qualified person delivering these services. 3. District hospital: Reduced the number of antenatal care sessions held per week. The sessions were reduced to ensure that sessions are full when held.

Lessons: 

Many human resource concepts such as goal alignment, objectives, tasks, etc. were completely new to QI teams at the facility level, and health workers had a hard time understanding the value-added of this work at the beginning of the process. However, as health workers have become more familiar with the concepts through coaching visits and learning sessions, they now are fully committed to the work and can see how changes in human resource positively affect their workload and the quality of care they deliver to patients. The human resource collaborative is an innovative approach because quality improvement teams are working on both human resource and clinical indicators simultaneously. This method has allowed them to clearly see the link between human resource inputs and clinical outcomes, and aligning their tasks with those of the district and the region helps them understand how they are directly contributing to improving health outcomes in Tahoua. Analyzing tasks also has allowed health workers and facilities to prioritize roles and responsibilities while improving the quality of care provided to patients. Another important lesson from this collaborative is the value of shared learning. Of the participating sites, there were five that had never done active management of the third state of labor and did not participate in a previous collaborative focused solely on essential obstetric and newborn care. However, through learning sessions and coaching, these health workers have now been trained in active management of the third stage of labor and are able to provide the essential part of obstetric care at their sites.

Region and Country: Africa, Sub Saharan, Niger

Topics: Active management of the third stage of labor, Performance management, Human Resources/Workforce Development, Maternal, Newborn and Child Health

Year: 
2009

Topics: FP-MCH integration, Maternal, Newborn and Child Health

Language: 
English
Description: 

 

This toolkit provides a comprehensive collection of best practices and evidence-based tools and documents on postpartum family planning (PPFP) developed through the ACCESS-FP Program. The first year postpartum is a time of great family planning need, but also a time when few services are accessible to women. This toolkit will assist policymakers, program managers, trainers and service providers to develop and implement effective service delivery approaches that address the family planning needs of the women they serve.
 

 

Fulltext URL: 
http://k4health.org/toolkits/ppfp
Author(s): 
Franco LM | Marquez L | Ethier K | Balsara Z | Isenhower W

Region and Country: Benin, Bolivia, Ecuador, Guatemala, Honduras, Nicaragua, Niger, Russia, Rwanda, Tanzania, Uganda, Vietnam

Topics: Family planning, Malaria, Maternal, Newborn and Child Health, Tuberculosis

Partners: 
Ministries of Health and implementing partners
Year: 
2009
Language: 
English
Description: 

This paper summarizes 10 years of evidence of the effectiveness of collaborative improvement in improving health outcomes and compliance with health care standards. The collaborative improvement approach was designed by the Institute for Healthcare Improvement (IHI) in the United States to produce rapid, significant improvements in a targeted area of health care. The paper was commissioned by USAID and analyzes the results achieved by over 1,300 teams of health care providers who participated in 27 improvement collaboratives supported by USAID during 1998-2008.   Data analyzed consisted of 135 time-series charts representing pooled data from groups of teams from 12 countries. All together, the data covered 81 distinct measures of compliance with standards and outcomes for maternal, newborn and child health, HIV/AIDS care, family planning, and malaria and tuberculosis diagnosis and treatment.

The study found that improvement collaboratives were able to achieve large increases in compliance with health care standards and in some cases, in health outcomes, across all care areas addressed, regardless of the baseline level of quality. Of the 135 analyzed time-series charts, 88% attained performance levels of at least 80%, and 76% reached at least 90%, even though more than half had baseline levels at 50% or below. The data provide compelling evidence that collaborative improvement can achieve large increases in performance, regardless of baseline level, and that results can be achieved relatively rapidly.  Across collaboratives, time series charts showed average increases of 52%.  Teams reached performance levels of 80% in about 13 months on average when baselines levels were below 50% and in about 6 months when baselines were above 50%. 

The analysis also suggests that moving beyond 80% performance requires different efforts (system redesign) to make high quality the routine and that deliberate spread reduces time required to raise performance of new sites.

The strength of a health system is measured in its ability to deliver good health outcomes. By achieving significant, sustained improvements in compliance with standards and outcomes, collaborative improvement is a viable tool for health systems strengthening in developing countries.
Link: 
application/pdf iconResults_of_Collaborative_Improvement_2009.pdf
Report cover
Author(s): 
Koniz-Booher, P.

Region and Country: Africa, Sub Saharan, Tanzania

Topics: Community health workers, At-risk populations, Employee Engagement, Growth monitoring/growth promotion, Nutritional support, Infant and young child feeding, Pediatric HIV/AIDS, PMTCT, HIV/AIDS, Human Resources/Workforce Development, Maternal, Newborn and Child Health

Language: 
English
Description: 

Counseling Cards
The counseling cards are intended for health workers to use during sessions with HIV-positive prenatal and postpartum women. Published in English and Swahili, the cards are tools that health workers can use to explain: the risk of transmission of HIV from mother to child when no preventive actions are taken; infant feeding options for HIV-positive mothers; the concept of acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding; and how to safely practice their chosen infant feeding method.

Risk of Passing HIV from Mother to Baby
Using this counseling card as a guide, the health worker can show the client a graphic depiction of the risk of passing HIV from HIV-positive women to their babies when NO preventive actions are taken. The card shows that most babies are infected with HIV during pregnancy and birth (approximately 20%). It also depicts the rate of babies who become infected with HIV through breastfeeding (approximately 15%) The health worker can use the card to illustrate that the majority of babies (approximately 65%) are not infected with HIV, but should be protected through the use of ARVs and safer infant feeding.

Infant Feeding Options
This counseling card is intended to assist healthcare providers counsel women who have tested HIV-positive. It offers graphic depictions of three of the most common methods being actively promoted for feeding infants of HIV-positive women in Tanzania so that the healthcare worker can guide the mother in determining the safest option for feeding her baby.

Infant Formula or Modified Cow's Milk as a Safe Option
This counseling card is directed to women who have tested HIV-positive and who are exploring their infant feeding options.This graphic job aid enables counselors to discuss whether using infant formula or modified cow’s milk presents a safe and secure alternative to breastfeeding, following AFASS criteria.

Risk of HIV passing from mother to baby if mother and baby take Nevirapine
Using this counseling card as a guide, the health worker can show the client that the risk of mother passing HIV to baby decreases the mother practices exclusive breastfeeding and mother and baby take Nevirapine.

How to Breastfeed
This job aid is intended to assist the counselor to give clear instructions to pregnant women on how to breastfeed. Illustrated, step-by-step instructions are presented to promote good positioning of the baby to prevent breast problems which can increase the transition of HIV through breastfeeding.

How to Hand Express Breast Milk
This counseling card graphically depicts the steps for the mother to follow to hand express breast milk, an important skill for all mothers to have, no matter what their status. It encourages the use of a cup rather than a bottle for feeding the baby.

Many Ways to Position and Attach Baby
Using this counseling card as a guide, the healthcare worker can show the mother a range of ways to position and attach the baby.

During the first 6 months, baby needs only breast milk
This card illustrates that during the first six months, the baby should be given only breast milk.The mother should avoid giving water, glucose water, and all other foods and drinks.

Danger Signs
Danger signs indicating that the baby should be immediately taken to the nearest health facility are illustrated.

 

Link: 
application/pdf iconRisk of Passing HIV from Mother to Baby_English.pdf
Link: 
application/pdf iconRisk of Passing HIV from Mother to Baby_Swahili.pdf
Link: 
application/pdf iconInfant Feeding Options_English.pdf
Link: 
application/pdf iconInfant Feeding Options_Swahili.pdf
Link: 
application/pdf iconInfant Formula or Modified Cow's Milk as a Safe Option _English.pdf
Link: 
application/pdf iconInfant Formula or Modified Cow's Milk as a Safe Option _Swahili.pdf
Link: 
application/pdf iconRisk of HIV passing from mother to baby if mother and baby take Nevirapine_English.pdf
Link: 
application/pdf iconRisk of HIV passing from mother to baby if mother and baby take Nevirapine_Swahili.pdf
Link: 
application/pdf iconHow to Breastfeed_English.pdf
Link: 
application/pdf iconHow to Breastfeed_Swahili.pdf
Link: 
application/pdf iconHow to Hand Express Breast Milk_English_0.pdf
Link: 
application/pdf iconHow to Hand Express Breast Milk_Swahili_0.pdf
Link: 
application/pdf iconMany Ways to Position and Attach Baby_English.pdf
Link: 
application/pdf iconMany Ways to Position and Attach Baby_Swahili.pdf
Link: 
application/pdf iconDuring the first 6 months, baby needs only breast milk_English.pdf
Link: 
application/pdf iconDuring the first 6 months, baby needs only breast milk_Swahili.pdf
Link: 
application/pdf iconDanger Signs_English.pdf
Link: 
application/pdf iconDanger Signs_Swahili.pdf
Author(s): 
Crigler L | Hill K | Furth R | Bjerregaard D

Topics: Community health workers, Community and home-based care for PLWHA, Motivation/incentives, Performance management, Recognition/remuneration, Retention of health workers/reducing attrition, Supervision, Training, HIV/AIDS, Maternal, Newborn and Child Health

Partners: 
Initiatives Inc.
Year: 
2011
Language: 
English
Description: 

A key element of USAID’s strategic approach to maternal and child health (MCH) is to increase by at least 100,000 the number of functional community health workers serving in USAID priority countries by 2013. At the request of the USAID MCH team, the Health Care Improvement (HCI) Project developed a tool that defines a set of key elements that are needed for community health worker programs to function effectively and measures how well programs meet these criteria.  These elements were defined based on a review of recent literature on CHW programs (see link below) and suggestions from expert reviewers. The CHW Program Assessment and Improvement Matrix (CHW AIM) tool examines 15 programmatic components that CHW programs should consider as important to successfully supporting CHWs.  These include: recruitment; the CHW role; initial training; continuing training; equipment and supplies; supervision; individual performance evaluation; incentives; community involvement; referral system; opportunity for advancement; documentation and information management; linkages to the health system; program performance evaluation: and community ownership. 

In applying the tool, each component is rated with a four-point scale ranging from non-functional to highly functional. In addition to assessing whether CHWs are part of functional programs, the tool includes lists of high impact, evidence-based interventions for MCH and HIV/TB services to guide assessment of which services the CHWs are currently performing.  

The instrument can be applied in a stakeholder meeting to assess the current status of a specific program and determine if the program as a whole is functional. Health workers within that program are then considered to be functional. In addition to helping determine whether a CHW program is functional, the tool also provides an action planning and resources guide to assist program managers in strengthening their community health worker programs.

The CHW AIM tool may be downloaded in its entirety below.  A brief review of recent literature on CHWs that helped to inform the development of the tool may also be downloaded.  Individual forms that are part of the tool may also be downloaded separately, by appendix, including comprehensive lists of maternal, newborn and child health and HIV/AIDS tasks that may be appropriate for CHWs. A powerpoint training for facilitators to use the CHW AIM toolkit is also provided below.
Link: 
application/pdf iconCHW AIM Toolkit_March2011.pdf
Link: 
application/pdf iconCHW literature review_Jan2010.pdf
Link: 
application/pdf iconCHW AIM A1_Participant Selection Form.pdf
Link: 
application/pdf iconCHW AIM A2_Document Review Guide and Checklist.pdf
Link: 
application/pdf iconCHW AIM A3_Validation Questionnaire.pdf
Link: 
application/pdf iconCHW AIM A4_Score Documentation Worksheet.pdf
Link: 
application/pdf iconCHW AIM A5_Score and Assessment Sheets.pdf
Link: 
application/pdf iconCHW AIM A6_Action Planning Framework.pdf
Link: 
application/vnd.ms-excel iconCopy of CHW AIM Appendix A5.xls
Link: 
application/msword iconCHW AIM Appendix A6.doc
Link: 
application/vnd.ms-powerpoint iconCHW AIM Trainers Guide slides.ppt
CHW AIM Toolkit cover
Author(s): 
Shawn Dick and Simon Hiltebeitel

Topics: Active management of the third stage of labor, Maternal, Newborn and Child Health

Year: 
2009
Description: 

This participant manual for the skill-building workshop delivered by staff of the USAID Health Care Improvement Project at the May 2009 Global Health Council annual conference was developed to guide workshop participants in designing their own improvement project applying the principles of modern health care improvement to the participant’s area of choice.  The manual guides the participant through eight steps in conceptualizing and designing an improvement project.  Using a fictional scenario for a health facility team that is trying to reduce post-partum hemorrhage through the introduction of active management of the third stage of labor, the manual provides examples of how the fictional team addressed each step in the process of designing their health care improvement activity.

Link: 
application/pdf iconDesigning your own improvement project workbook_May09.pdf
Author(s): 
Ms. Linda Bruce, PATH

Topics: Maternal, Newborn and Child Health

Language: 
English
Description: 

Delivery kits are prepackaged, single use, disposable kits that contain essential items for conducting a clean delivery.
A presentation from the Job Aids Symposium.

Link: 
application/pdf iconBruce Clean Delivery Kit.pdf
Link: 
application/pdf iconBruce Transcript.pdf

Region and Country: Africa, Sub Saharan, Benin

Topics: Antenatal care, Birth preparedness, Essential newborn care, Maternal, Newborn and Child Health

Partners: 
Projet Intégré de la Santé Familiale, Ministry of Health
Language: 
English
Description: 

The impact of counseling and the quality of services provided by both skilled and unskilled health care workers within government facilities in Zou/Collines, Benin was assessed both prior to and following the intervention trial. At both points, baseline/endline data was collected on the quality of counseling, health workers' knowledge of maternal care, in addition to facility-based newborn care practices. At this time, a pictorial set of counseling cards was also introduced, which were to be used to improve upon current service delivery. Fourteen public health maternities were included in the study, of which seven were randomly assigned to interventions and the other seven to control groups. Methods of evaluation consisted of direct observation and exit interviews with pregnant women and new mothers, in addition to extensive surveying of both skilled and unskilled workers.

Results indicated that the baseline quality of skilled provider counseling was inadequate; however, it improved substantially, as a result of training, increased supervision, and the implementation of job aids. This was directly correlated with improved maternal care knowledge in areas such as birth preparedness, maternal and newborn danger signs, newborn care, and healthy home practices. The study confirmed that lay providers were also capable of achieving comparably high performance levels using job aids. In conclusion, task delegation and job aids both significantly improve the quality of counseling provided by health care workers, in addition to increasing patient understanding of maternal and newborn care.

Link: 
application/pdf icon2-Page Flyer
Author(s): 
USAID Health Care Improvement Project

Region and Country: Niger

Topics: Maternal, Newborn and Child Health

Year: 
2008
Language: 
English
Description: 

On average a Nigerien woman faces a 1 in 7 risk of dying from pregnancy complications over the course of her lifetime, one of the highest maternal mortality risks in the world. Post-partum hemorrhage (PPH) is the leading cause of maternal mortality in Niger followed by sepsis and eclampsia. For every maternal complication, there is a high rate of newborn death and morbidity. In 2006, USAID’s Quality Assurance Project launched the Essential Obstetric and Newborn Care (EONC) Collaborative in Niger to improve quality of maternal and newborn care services according to evidence-based best practices.

Link: 
application/pdf iconNiger.QIMatNewborn.May08.pdf
Author(s): 
Hermida J | Robalino ME | Vaca L | Ayabaca P | Romero P

Region and Country: Ecuador, South America

Topics: Active management of the third stage of labor, Antenatal care, Essential newborn care, Essential obstetric care, Maternal, Newborn and Child Health

Year: 
2005
Language: 
English
Description: 

The present document reports on an operations research study conducted by the Quality Assurance Project (QAP) to examine the process of institutionalizing a Continuous Quality Improvement (CQI) process within the context of the reforms introduced by the Law for the Provision of Free Maternity Services and Child Care. The objectives of the study were: a) Describe and document the process, methods, and results of scaling-up and institutionalizing a quality assurance mechanism within the Free Maternity Program of the Ministry of Health of Ecuador; b) Explore associations between the degree of institutionalization achieved and the presence of reforms introduced by the Law, believed to be favorable to the QA institutionalization process; and c) Synthesize lessons learned that can be adapted and applied in other Latin American countries. The main research questions of the study were: a) Is it possible to achieve expansion of CQI through a decentralized intervention involving staff from provincial offices of the MOH (CQI facilitators), who replicate training sessions and locally support and monitor the work of quality improvement teams?; b) Which are the main factors that facilitate or constrain the application of the CQI model?; c) What is the model's cost?; d) What are the results in terms of the extent of CQI expansion and quality improvement of healthcare? (excerpt)

Link: 
application/pdf iconScaling up and Institutionalizing CQI in Ecuador.LACHSR No 65.pdf