Helen Prytherch

“Quality of prenatal and maternal care: bridging the know-do gap” (QUALMAT study): an electronic clinical decision support system for rural Sub-Saharan Africa

BackgroundDespite strong efforts to improve maternal care, its quality remains deficient in many countries of Sub-Saharan Africa as persistently high maternal mortality rates testify. The QUALMAT study seeks to improve the performance and motivation of rural health workers and ultimately quality of primary maternal health care services in three African countries Burkina Faso, Ghana, and Tanzania. One major intervention is the introduction of a computerized Clinical Decision Support System (CDSS) for rural primary health care centers to be used by health care workers of different educational levels.MethodsA stand-alone, java-based software, able to run on any standard hardware, was developed based on assessment of the health care situation in the involved countries. The software scope was defined and the final software was programmed under consideration of test experiences. Knowledge for the decision support derived from the World Health Organization (WHO) guideline “Pregnancy, Childbirth, Postpartum and Newborn Care; A Guide for Essential Practice”.ResultsThe QUALMAT CDSS provides computerized guidance and clinical decision support for antenatal care, and care during delivery and up to 24 hours post delivery. The decision support is based on WHO guidelines and designed using three principles: (1) Guidance through routine actions in maternal and perinatal care, (2) integration of clinical data to detect situations of concern by algorithms, and (3) electronic tracking of peri- and postnatal activities. In addition, the tool facilitates patient management and is a source of training material. The implementation of the software, which is embedded in a set of interventions comprising the QUALMAT study, is subject to various research projects assessing and quantifying the impact of the CDSS on quality of care, the motivation of health care staff (users) and its health economic aspects. The software will also be assessed for its usability and acceptance, as well as for its influence on workflows in the rural setting of primary health care in the three countries involved.ConclusionThe development and implementation of a CDSS in rural primary health care centres presents challenges, which may be overcome with careful planning and involvement of future users at an early stage. A tailored software with stable functionality should offer perspectives to improve maternal care in resource-poor settings.Trial registrationhttp://www.clinicaltrials.gov/NCT01409824.

The unmet need for Emergency Obstetric Care in Tanga Region, Tanzania

BackgroundImproving maternal health by reducing maternal mortality constitutes the fifth Millennium Development Goal and represents a key public health challenge in the United Republic of Tanzania. In response to the need to evaluate and monitor safe motherhood interventions, this study aims at assessing the coverage of obstetric care according to the Unmet Obstetric Need (UON) concept by obtaining information on indications for, and outcomes of, major obstetric interventions. Furthermore, we explore whether this concept can be operationalised at district level.MethodsA two year study using the Unmet Obstetric Need concept was carried out in three districts in Tanga Region, Tanzania. Data was collected prospectively at all four hospitals in the region for every woman undergoing a major obstetric intervention, including indication and outcome. The concept was adapted to address differentials in access to emergency obstetric care between districts and between rural and urban areas. Based upon literature and expert consensus, a threshold of 2% of all deliveries was used to define the expected minimum requirement of major obstetric interventions performed for absolute maternal indications.ResultsProtocols covering 1,260 complicated deliveries were analysed. The percentage of major obstetric interventions carried out in response to an absolute maternal indication was only 71%; most major obstetric interventions (97%) were caesarean sections. The most frequent indication was cephalo-pelvic-disproportion (51%). The proportion of major obstetric interventions for absolute maternal indications performed amongst women living in urban areas was 1.8% of all deliveries, while in rural areas it was only 0.7%. The high proportion (8.3%) of negative maternal outcomes in terms of morbidity and mortality, as well as the high perinatal mortality of 9.1% (still birth 6.9%, dying within 24 hours 1.7%, dying after 24 hours 0.5%) raise concern about the quality of care being provided.ConclusionBased on the 2% threshold, Tanga Region – with an overall level of major obstetric interventions for absolute maternal indications of 1% and a caesarean section rate of 1.4% – has significant unmet obstetric need with a considerable rural-urban disparity. The UON concept was found to be a suitable tool for evaluating and monitoring the coverage of obstetric care at district level.

Motivation and incentives of rural maternal and neonatal health care providers: a comparison of qualitative findings from Burkina Faso, Ghana and Tanzania

BackgroundIn Burkina Faso, Ghana and Tanzania strong efforts are being made to improve the quality of maternal and neonatal health (MNH) care. However, progress is impeded by challenges, especially in the area of human resources. All three countries are striving not only to scale up the number of available health staff, but also to improve performance by raising skill levels and enhancing provider motivation.MethodsIn-depth interviews were used to explore MNH provider views about motivation and incentives at primary care level in rural Burkina Faso, Ghana and Tanzania. Interviews were held with 25 MNH providers, 8 facility and district managers, and 2 policy-makers in each country.ResultsAcross the three countries some differences were found in the reasons why people became health workers. Commitment to remaining a health worker was generally high. The readiness to remain at a rural facility was far less, although in all settings there were some providers that were willing to stay. In Burkina Faso it appeared to be particularly difficult to recruit female MNH providers to rural areas. There were indications that MNH providers in all the settings sometimes failed to treat their patients well. This was shown to be interlinked with differences in how the term ‘motivation’ was understood, and in the views held about remuneration and the status of rural health work. Job satisfaction was shown to be quite high, and was particularly linked to community appreciation. With some important exceptions, there was a strong level of agreement regarding the financial and non-financial incentives that were suggested by these providers, but there were clear country preferences as to whether incentives should be for individuals or teams.ConclusionsUnderstandings of the terms and concepts pertaining to motivation differed between the three countries. The findings from Burkina Faso underline the importance of gender-sensitive health workforce planning. The training that all levels of MNH providers receive in professional ethics, and the way this is reinforced in practice require closer attention. The differences in the findings across the three settings underscore the importance of in-depth country-level research to tailor the development of incentives schemes.

The challenges of developing an instrument to assess health provider motivation at primary care level in rural Burkina Faso, Ghana and Tanzania

BACKGROUND The quality of health care depends on the competence and motivation of the health workers that provide it. In the West, several tools exist to measure worker motivation, and some have been applied to the health sector. However, none have been validated for use in sub-Saharan Africa. The complexity of such tools has also led to concerns about their application at primary care level. OBJECTIVE To develop a common instrument to monitor any changes in maternal and neonatal health (MNH) care provider motivation resulting from the introduction of pilot interventions in rural, primary level facilities in Ghana, Burkina Faso, and Tanzania. DESIGN Initially, a conceptual framework was developed. Based upon this, a literature review and preliminary qualitative research, an English-language instrument was developed and validated in an iterative process with experts from the three countries involved. The instrument was then piloted in Ghana. Reliability testing and exploratory factor analysis were used to produce a final, parsimonious version. RESULTS AND DISCUSSION This paper describes the actual process of developing the instrument. Consequently, the concepts and items that did not perform well psychometrically at pre-test are first presented and discussed. The final version of the instrument, which comprises 42 items for self-assessment and eight for peer-assessment, is then shown. This is followed by a presentation and discussion of the findings from first use of the instrument with MNH providers from 12 rural, primary level facilities in each of the three countries. CONCLUSIONS It is possible to undertake work of this nature at primary health care level, particularly if the instruments are kept as straightforward as possible and well introduced. However, their development requires very lengthy preparatory periods. The effort needed to adapt such instruments for use in different countries within the region of sub-Saharan Africa should not be underestimated.Background: The quality of health care depends on the competence and motivation of the health workers that provide it. In the West, several tools exist to measure worker motivation, and some have been applied to the health sector. However, none have been validated for use in sub-Saharan Africa. The complexity of such tools has also led to concerns about their application at primary care level. Objective: To develop a common instrument to monitor any changes in maternal and neonatal health (MNH) care provider motivation resulting from the introduction of pilot interventions in rural, primary level facilities in Ghana, Burkina Faso, and Tanzania. Design: Initially, a conceptual framework was developed. Based upon this, a literature review and preliminary qualitative research, an English-language instrument was developed and validated in an iterative process with experts from the three countries involved. The instrument was then piloted in Ghana. Reliability testing and exploratory factor analysis were used to produce a final, parsimonious version. Results and discussion: This paper describes the actual process of developing the instrument. Consequently, the concepts and items that did not perform well psychometrically at pre-test are first presented and discussed. The final version of the instrument, which comprises 42 items for self-assessment and eight for peer-assessment, is then shown. This is followed by a presentation and discussion of the findings from first use of the instrument with MNH providers from 12 rural, primary level facilities in each of the three countries. Conclusions: It is possible to undertake work of this nature at primary health care level, particularly if the instruments are kept as straightforward as possible and well introduced. However, their development requires very lengthy preparatory periods. The effort needed to adapt such instruments for use in different countries within the region of sub-Saharan Africa should not be underestimated.

HIV-related travel restrictions: trends and country characteristics.

Introduction Increasingly, HIV-seropositive individuals cross international borders. HIV-related restrictions on entry, stay, and residence imposed by countries have important consequences for this mobile population. Our aim was to describe the geographical distribution of countries with travel restrictions and to examine the trends and characteristics of countries with such restrictions. Methods In 2011, data presented to UNAIDS were used to establish a list of countries with and without HIV restrictions on entry, stay, and residence and to describe their geographical distribution. The following indicators were investigated to describe the country characteristics: population at mid-year, international migrants as a percentage of the population, Human Development Index, estimated HIV prevalence (age: 15–49), presence of a policy prohibiting HIV screening for general employment purposes, government and civil society responses to having non-discrimination laws/regulations which specify migrants/mobile populations, government and civil society responses to having laws/regulations/policies that present obstacles to effective HIV prevention, treatment, care, and support for migrants/mobile populations, Corruption Perception Index, and gross national income per capita. Results HIV-related restrictions exist in 45 out of 193 WHO countries (23%) in all regions of the world. We found that the Eastern Mediterranean and Western Pacific Regions have the highest proportions of countries with these restrictions. Our analyses showed that countries that have opted for restrictions have the following characteristics: smaller populations, higher proportions of migrants in the population, lower HIV prevalence rates, and lack of legislation protecting people living with HIV from screening for employment purposes, compared with countries without restrictions. Conclusion Countries with a high proportion of international migrants tend to have travel restrictions – a finding that is relevant to migrant populations and travel medicine providers alike. Despite international pressure to remove travel restrictions, many countries continue to implement these restrictions for HIV-positive individuals on entry and stay. Since 2010, the United States and China have engaged in high profile removals. This may be indicative of an increasing trend, facilitated by various factors, including international advocacy and the setting of a UNAIDS goal to halve the number of countries with restrictions by 2015.Introduction Increasingly, HIV-seropositive individuals cross international borders. HIV-related restrictions on entry, stay, and residence imposed by countries have important consequences for this mobile population. Our aim was to describe the geographical distribution of countries with travel restrictions and to examine the trends and characteristics of countries with such restrictions. Methods In 2011, data presented to UNAIDS were used to establish a list of countries with and without HIV restrictions on entry, stay, and residence and to describe their geographical distribution. The following indicators were investigated to describe the country characteristics: population at mid-year, international migrants as a percentage of the population, Human Development Index, estimated HIV prevalence (age: 15-49), presence of a policy prohibiting HIV screening for general employment purposes, government and civil society responses to having non-discrimination laws/regulations which specify migrants/mobile populations, government and civil society responses to having laws/regulations/policies that present obstacles to effective HIV prevention, treatment, care, and support for migrants/mobile populations, Corruption Perception Index, and gross national income per capita. Results HIV-related restrictions exist in 45 out of 193 WHO countries (23%) in all regions of the world. We found that the Eastern Mediterranean and Western Pacific Regions have the highest proportions of countries with these restrictions. Our analyses showed that countries that have opted for restrictions have the following characteristics: smaller populations, higher proportions of migrants in the population, lower HIV prevalence rates, and lack of legislation protecting people living with HIV from screening for employment purposes, compared with countries without restrictions. Conclusion Countries with a high proportion of international migrants tend to have travel restrictions - a finding that is relevant to migrant populations and travel medicine providers alike. Despite international pressure to remove travel restrictions, many countries continue to implement these restrictions for HIV-positive individuals on entry and stay. Since 2010, the United States and China have engaged in high profile removals. This may be indicative of an increasing trend, facilitated by various factors, including international advocacy and the setting of a UNAIDS goal to halve the number of countries with restrictions by 2015.

The internal migration between public and faith-based health providers: a cross-sectional, retrospective and multicentre study from southern Tanzania

To assess the magnitude, direction and underlying dynamics of internal health worker migration between public and faith‐based health providers from a hospital perspective.

Working Atmosphere and Job Satisfaction of Health Care Staff in Kenya: An Exploratory Study.

Background. Job satisfaction and working atmosphere are important for optimal health care delivery. The study aimed to document working atmosphere and job satisfaction of health care professionals in Kenya and to explore associations between job satisfaction, staff characteristics, and working atmosphere. Methods. Data from the integrated quality management system (IQMS) for the health sector in Kenya were used. Job satisfaction was measured with 10 items and with additional 5 items adapted to job situation in Kenya. Working atmosphere was measured with 13 item questionnaire. A stepwise linear regression analysis was performed with overall job satisfaction and working atmosphere, aspects of job satisfaction, and individual characteristics. Results. Out of 832 questionnaires handed out, 435 questionnaires were completed (response rate: 52.3%). Health care staff indicated high commitment to provide quality services and low levels regarding the adequacy and functionality of equipment at their work station. The aspect “support of the ministry of health” (β = 0.577) showed the highest score of explained variance (32.9%) regarding overall job satisfaction. Conclusions. IQMS which also evaluates job satisfaction and working atmosphere of health care staff provides a good opportunity for strengthening the recruitment and retention of health care staff as well as improving the provision of good quality of care.

Nesting doctoral students in collaborative North–South partnerships for health systems research

Background The European Union (EU) supports North–South Partnerships and collaborative research projects through its Framework Programmes and Horizon 2020. There is limited research on how such projects can be harnessed to provide a structured platform for doctoral level studies as a way of strengthening health system research capacity in sub-Saharan Africa (SSA). Objective The aim of this study was to explore the challenges of, and facilitating factors for, ‘nesting’ doctoral students in North–South collaborative research projects. The term nesting refers to the embedding of the processes of recruiting, supervising, and coordinating doctoral students in the overall research plan and processes. Design This cross-sectional qualitative study was undertaken by the EU-funded QUALMAT Project. A questionnaire was implemented with doctoral students, supervisors, and country principal investigators (PIs), and content analysis was undertaken. Results Completed questionnaires were received from nine doctoral students, six supervisors, and three country PIs (86% responses rate). The doctoral students from SSA described high expectations about the input they would receive (administrative support, equipment, training, supervision). This contrasted with the expectations of the supervisors for proactivity and self-management on the part of the students. The rationale for candidate selection, and understandings of the purpose of the doctoral students in the project were areas of considerable divergence. There were some challenges associated with the use of the country PIs as co-supervisors. Doctoral student progress was at times impeded by delays in the release of funding instalments from the EU. The paper provides a checklist of essential requirements and a set of recommendations for effective nesting of doctoral students in joint North–South projects. Conclusion There are considerable challenges to the effective nesting of doctoral students within major collaborative research projects. However, ways can be found to overcome them. The nesting process ultimately helped the institutions involved in this example to take better advantage of the opportunities that collaborative projects offer to foster North–South partnerships as a contribution to the strengthening of local research capacity.

An in-depth, exploratory assessment of the implementation of the National Health Information System at a district level hospital in Tanzania

BackgroundA well functioning Health Information System (HIS) is crucial for effective and efficient health service delivery. In Tanzania there is a national HIS called Mfumo wa Taarifa za Uendeshaji Huduma za Afya (MTUHA). It comprises a guideline/manual, a series of registers for primary data collection and secondary data books where information from the registers is totalled or used for calculations.MethodsA mix of qualitative methods were used. These included key informant interviews; staff interviews; participant observations; and a retrospective analysis of the hospital’s 2010 MTUHA reporting documents and the hospital’s development plan.ResultsAll staff members acknowledged data collection as part of their job responsibilities. However, all had concerns about the accuracy of MTUHA data. Access to training was limited, mathematical capabilities often low, dissemination of MTUHA knowledge within the hospital poor, and a broad understanding of the HIS’s full capabilities lacking.Whilst data collection for routine services functioned reasonably well, filling of the secondary data tools was unsatisfactory. Internal inconsistencies between the different types of data tools were found. These included duplications, and the collection of data that was not further used. Sixteen of the total 72 forms (22.2%) that make up one of the key secondary data books (Hospital data/MTUHA book 2) could not be completed with the information collected in the primary data books.Moreover, the hospital made no use of any of the secondary data. The hospital’s main planning document was its development plan. Only 3 of the 22 indicators in this plan were the same as indicators in MTUHA, the information for 9 more was collected by the MTUHA system but figures had to be extracted and recalculated to fit, while for the remaining 10 indicators no use could be made of MTUHA at all.ConclusionThe HIS in Tanzania is very extensive and it could be advisable to simplify it to the core business of data collection for routine services. Alternatively, the more comprehensive, managerial aspects could be sharpened for each type of facility, with a focus upon the hospital level. In particular, hospital planning documents need to be more closely aligned with MTUHA indicators.

Can performance-based incentives improve motivation of nurses and midwives in primary facilities in northern Ghana? A quasi-experimental study

Background Lack of an adequate and well-performing health workforce has emerged as the biggest barrier to scaling up health services provision in sub-Saharan Africa. As the global community commits to the Sustainable Development Goals and universal health coverage, health workforce challenges are critical. In northern Ghana, performance-based incentives (PBIs) were introduced to improve health worker motivation and service quality. Objective The goal of this study was to determine the impact of PBIs on maternal health worker motivation in two districts in northern Ghana. Design A quasi-experimental study design with pre- and post-intervention measurement was used. PBIs were implemented for 2 years in six health facilities in Kassena-Nankana District with six health facilities in Builsa District serving as comparison sites. Fifty pre- and post-intervention structured interviews and 66 post-intervention in-depth interviews were conducted with health workers. Motivation was assessed using constructs for job satisfaction, pride, intrinsic motivation, timelines/attendance, and organisational commitment. Quantitative data were analysed to determine changes in motivation between intervention and comparison facilities pre- and post-intervention using STATA™ version 13. Qualitative data were analysed thematically using NVivo 10 to explore possible reasons for quantitative findings. Results PBIs were associated with slightly improved maternal health worker motivation. Mean values for overall motivation between intervention and comparison health workers were 0.6 versus 0.7 at baseline and 0.8 versus 0.7 at end line, respectively. Differences at baseline and end line were 0.1 (p=0.40 and p=0.50 respectively), with an overall 0.01 difference in difference (p=0.90). Qualitative interviews indicated that PBIs encouraged health workers to work harder and be more punctual, increasing reported pride and job satisfaction. Conclusions The results contribute evidence on the effects of PBIs on motivational constructs among maternal health workers in primary care facilities in northern Ghana. PBIs appeared to improve motivation, but not dramatically, and the long-term and unintended effects of their introduction require additional study.Background Lack of an adequate and well-performing health workforce has emerged as the biggest barrier to scaling up health services provision in sub-Saharan Africa. As the global community commits to the Sustainable Development Goals and universal health coverage, health workforce challenges are critical. In northern Ghana, performance-based incentives (PBIs) were introduced to improve health worker motivation and service quality. Objective The goal of this study was to determine the impact of PBIs on maternal health worker motivation in two districts in northern Ghana. Design A quasi-experimental study design with pre- and post-intervention measurement was used. PBIs were implemented for 2 years in six health facilities in Kassena-Nankana District with six health facilities in Builsa District serving as comparison sites. Fifty pre- and post-intervention structured interviews and 66 post-intervention in-depth interviews were conducted with health workers. Motivation was assessed using constructs for job satisfaction, pride, intrinsic motivation, timelines/attendance, and organisational commitment. Quantitative data were analysed to determine changes in motivation between intervention and comparison facilities pre- and post-intervention using STATA™ version 13. Qualitative data were analysed thematically using NVivo 10 to explore possible reasons for quantitative findings. Results PBIs were associated with slightly improved maternal health worker motivation. Mean values for overall motivation between intervention and comparison health workers were 0.6 versus 0.7 at baseline and 0.8 versus 0.7 at end line, respectively. Differences at baseline and end line were 0.1 (p=0.40 and p=0.50 respectively), with an overall 0.01 difference in difference (p=0.90). Qualitative interviews indicated that PBIs encouraged health workers to work harder and be more punctual, increasing reported pride and job satisfaction. Conclusions The results contribute evidence on the effects of PBIs on motivational constructs among maternal health workers in primary care facilities in northern Ghana. PBIs appeared to improve motivation, but not dramatically, and the long-term and unintended effects of their introduction require additional study.