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Improving Quality of Care in Partnership with Governments and Communities_5.8.14
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Improving Quality of Care in Partnership with Governments and Communities_5.8.14

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  • background on model, emphasizing value-add as a holistic approach that accounts for community system, and health & governance systems– all of which are necessary to successful implementation of the modelCommunity:Clinical:PREVENTION:give background on AMSTL, set up that much of this model is compiling known effective interventions and building capacity to implement them in an accurate and timely fashion)AMSTL: Administration of uterotonic drug, Controlled cord tractions with simultaneous countertraction of the uterusFundal massage after delivery of the placentaReduces PPH incidence by up to 60% when HRH are trained, injection safety is assured, and uterotonics, cold chain, etc are in placeIDENTIFY:MANAGE:Government:
  • Donor support from:MacArthur Foundation (past)NigeriaIndiaTanzaniaMerck 4 Mothers (current)NigeriaIndiaPeruElma & Vodafone (current)Tanzania
  • Significantly reduces blood loss, time to recovery from shock, and– for those with PPH due to uterine atony who received oxytocin, the Life Wrap had significant effect on blood loss independent of oxytocin.Individuals with brief training can safely apply this first-aid deviceThe garment costs $60 USD and can be worn up to 50 times (with proper care). --$60 for up to 50 lives saved
  • So often in our industry, we latch on to technologies, innovations, new vaccines as the holy grail for what ails us. The story with the Life Wrap & our CCA-PPH+ model only highlights this. Despite all our own arguments to the contrary and even MacArthur’s evaluation findings, our current projects still face challenges in ensuring total fidelity to the entirety of the model when negotiating with in-country Ministries of Health. This is telling. What is it about our industry that brings so many of us to want the silver bullet– even when we know from our own experience that silver bullets don’t really exist? It’s because these softer touch areas– the dynamics of human interaction, of dynamic systems, of the constellation of political, social, and infrastructural realities– are nebulous, hard-to-pin-down, and harder still to find user manuals for. But that is precisely the kind of information we need– the “user manual” to navigate the realities of global health implementation. To understand how to take an evidence-based intervention or model and yield the same value from it when applied in our own settings or contexts.At Pathfinder, we’re increasingly interested in these soft-touch questions. The “how” questions that we believe we and our sister organizations must get better at discussing, better at answering, better at sharing.
  • What does it take to implement a successful technical strategy?How can we get better at asking the right questions, and getting the right answers?
  • Some call this implementation science, but it has many names right now. World Bank is seeing the “science of delivery” as their next frontier. What does it take to deliver, to implement the interventions we know to be effective? What does effective delivery look like?Emphasis: context-specific knowledge, constant adjustments, focus on the details of implementationWhat does it take for an implementer to understand the “how” questions that are critical for implementation?
  • Re: reduction of PPH by miso stat– from WHO. PROPOSAL FOR THE INCLUSION OF MISOPROSTOL IN THE WHO MODEL LIST OF ESSENTIAL MEDICINES, 2009. Available at http://www.who.int/selection_medicines/committees/expert/17/application/Miso_Incl_1.pdf

Improving Quality of Care in Partnership with Governments and Communities_5.8.14 Improving Quality of Care in Partnership with Governments and Communities_5.8.14 Presentation Transcript

  • Community and Clinical Action: Maternal and Newborn Health Graciela Salvador-Davila, Senior Technical Advisor for Maternal and Newborn Health| Global Health Practitioner Conference, May 2014
  • BACKGROUND | PPH • PPH is the leading direct cause of maternal deaths worldwide. – PPH accounts for nearly 1/4th of maternal mortalities • Time is a major issue. – A woman can die within 2 hours of onset of PPH if she does not receive proper treatment • Barriers to life-saving care are many. – Slow recognition of danger, need for care – Distance – Lack of funds – Lack of transport – Weak referral systems – Stock-outs – Inadequate provider skills and attitudes
  • PATHFINDER’S CCA-PPH+ MODEL– IMPLEMENTATION COMPONENTS
  • PERU Piura, Lima and Ayacucho States NIGERIA Katsina, Kano, Lagos, Nassarawa, Oyo, Yobe, Ebonyi, BANGLADESH Kishoreganj District INDIA Maharashtra, Rajasthan, Bihar, Tamil Nadu , (Orissa) States TANZANIA Refugee camp and host community settings in Kigoma PATHFINDER’S CCA-PPH+ MODEL- GLOBAL APPLICATION
  • THE COMMUNITY-FACILITY LINKAGE CONTINUUMCOMMUNITYAWARENESS Widespread community knowledge of risks of unskilled birth attendance, & pregnancy and delivery danger signs RECOGNITIONOFNEED Family members, friend s, CHWs capable of identifying PPH Community systems activated to respond TRANSPORT Community- level drivers coordinate with CHWs and/or family to transport women from community to facility CLINICLEVELCARE Facility-level providers receive woman, apply Life Wrap, & initiate referrals for life-saving care as necessary Community-wide education, sensitization, CHW and/or family training Community-transport systems established; contact information made widely available; community creates incentives for drivers Provider/CHW sensitization to ensure positive, productive working relationships; facility-wide training on Life Wrap; provider trainings
  • THE CCA-PPH+ CONCEPTPREVENTION Majority of PPH cases stopped before they start RECOGNITION Capacity to identify PPH, so transport is timely URGENTCARE Providers have the skills necessary to address PPH LifeWrap&SHOCKRx First aid device applied to allow for referral to secondary level DEFINITIVERx Transport Appropriate care delivered 2% of women with PPH go into shock 25% of maternal mortality is caused by hemorrhage @ health system level THE TREATMENT CONTINUUM
  • THE NON-PNUEMATIC ANTI-SHOCK GARMENT (LIFE WRAP)
  • THE NON-PNUEMATIC ANTI-SHOCK GARMENT (LIFE WRAP)  Evidence-based  Simple technology  Low-cost = Object of desire (and forget about the rest!)
  • 2011 external evaluation of Pathfinder CCA-PPH+ programs. Among the findings:  “PPH in the facilities is decreasing…”  “Promoting just the Life Wrap is not likely to have a large impact on mortality because the Life Wrap is used in only the most extreme cases (only 2% of PPH cases lead to shock)… preventing PPH in the first place (as opposed to treating it when it gets out of hand) helps many, many more women.”  “…packaging of the full range of interventions to address PPH was unique and we believe was what made the difference…”  “The Life Wrap provided an entrée into the medical systems of both India and Nigeria; it served as the ‘admission ticket’ for the introduction of the continuum of care model.”  “the most effective way to address PPH is not through the Life Wrap but by strengthening the quality and availability of basic obstetrical care, including AMSTL…” THINKING ABOUT THE LIFE WRAP & CONTINUUM OF CARE MACARTHUR EVALUATION FINDINGS
  •  “All the model does is systematically highlight the various steps that need to be followed to provide very basic obstetrical care. But it is precisely because the required interventions are so basic, so old and ‘ho-hum’ that the introduction of the Life Wrap was so important.”  “Whether the same level of entrée could have been achieved by Pathfinder without the allure of the Life Wrap can be disputed. But what is undeniable is the role the Life Wrap played in introducing the continuum of care model– a model that definitely strengthened the government health systems in both countries.” THINKING ABOUT THE LIFE WRAP & CONTINUUM OF CARE EVALUATION FINDINGS
  • IMPLEMENTATION SCIENCE The right questions, the right answers?
  • “This is the next frontier …helping to advance a ‘science of delivery.’ Because we know that delivery isn’t easy – it’s not as simple as just saying ‘this works, this doesn’t.’ Effective delivery demands context- specific knowledge. It requires constant adjustments, a willingness to take smart risks, and a relentless focus on the details of implementation.” -Jim Yong Kim, World Bank President 2012 Annual Plenary Session
  • IMPLEMENTATION SCIENCE FOR MATERNAL HEALTH • The world is seeing progress in stemming maternal deaths – nearly a 50% decline in MMR between 1990 and 2010. • Looking forward to post-2015, there is still work to be done. • Majority of maternal death causes are preventable. • From a clinical practice perspective, we know what works.  So what do we need to know to replicate “what works” & take it to scale?
  • Z IMPLEMENTATION SCIENCE FOR PPH & THE CCA-PPH+ MODEL
  • PREVENTION Majority of PPH cases stopped before they start RECOGNITION Community members can identify severe PPH LifeWrap& SHOCKRx First aid device applied at community- level prior to initiation of transport URGENTCARE Providers have the skills necessary to address PPH for stabilization DEFINITIVERx Life-saving care delivered (surgery, blood transfusion, medication) STRETCHING THE CCA-PPH+ TREATMENT CONTINUUM TO COMMUNITY LEVEL • 25% of maternal mortality is caused by hemorrhage. • 2/3rds of women with PPH have no identifiable risk factors. • More than 50% of women in resource-limited settings have no skilled birth attendance and deliver at community-level. Community-level distribution of misoprostol to prevent PPH (Potential to reduce PPH incidence by up to 50%, and severe PPH by 80%) @ community level @ health system level
  • LOGICAL ORDER OF IMPLEMENTATION The order of implementation is generally: 1. Advocacy: Work with the government and professional organizations, so all understand and support the initiative. Also donors, other linkage with other potential partners. 2. Prepare all levels of facilities, but start with the tertiary/referral level to make sure it is EOC referral ready, including AMTSL and the use of the Life Wrap, then moving to secondary, and primary levels once the referral hospitals are ready. 3. Once each facility level is ready, work with government supported front line workers and CBO’s to engage the communities in raising awareness of danger signs, and how to avoid the first 3 delays at community level including an established transport system.
  • THE CCA-PPH MODEL: A SUMMARY • The CCA-PPH Model is comprehensive, practical, and adaptable • The elements of the model taken together can have a significant impact on maternal mortality • Elements implemented individually have less impact • The model can be adapted for other causes of maternal mortality such as pre-eclampsia and eclampsia, sepsis, and prolonged labor • The Project CD contains the PPH curriculum, the training video and a toolkit with job aids, a community survey tool and data collection instruments
  • ADDING PE/ECLAMPSIA TO THE CCA-PPH MODEL • Pre-eclampsia/eclampsia (PE/E) can be easily rolled into the CAA/PPH Continuum of Care, utilizing the organized facility levels and community engagement systems already in place for PPH. • This can be done after the PPH components are in place, or developed at the same time as the PPH components. • Similarly, all the major causes of maternal mortality can be addressed with these same facility-community systems (sepsis, obstructed/prolonged labor, unsafe abortion)
  • Program Monitoring and Evaluation Plan EffectivenessIndicators Performance Monitoring System FundsStaffing Inputs • Community sensitization and engagement • Frontline workers trained in IEC and referral • Community organizations equipped with emergency transportation • IEC materials distributed • Effective referral systems developed • Job aids/protocols developed/adapted • Health providers trained • Supervision provided for sustained and improved quality of care • Life Wraps provided to facilities • Advocacy meetings with gov’t officials and other key stakeholders Activities Objectives Performance(output)Indicators OutcomeIndicators GoalEffects 1. Increase awareness of community members of the danger signs of PPH and knowledge of technologies 2. Improve the capacity of community members to make the decision to seek medical care for PPH 3. Increase the ability of community members to identify and reach medical care for obstetric emergencies and complications including PPH 4. Improve the capacity of health care providers to provide high-quality appropriate care ImpactIndicators Fig. 1. Program Framework: CCA-PPH Model Decrease rates of PPH and shock Decrease maternal mortality related to PPH • Increased access to and use of emergency transportation • Increased referrals from communities to lower level facilities to higher level facilities • Job aids/protocols approved and in place • Increased access to equipment and commodities • Increased practice of AMTSL by providers • Increased use of standard tools for estimating blood loss • Appropriate and timely management of PPH • Increased use of Life Wrap for management of shock
  • twitter.com/PathfinderInt facebook.com/PathfinderInternational Youtube/user/PathfinderInt For more information contact: Graciela Salvador-Davila, Senior Technical Advisor for Maternal and Newborn Health GDavila@pathfinder.org Thank you!