Kedar S. Mate

Improving a mother to child HIV transmission programme through health system redesign: quality improvement, protocol adjustment and resource addition.

Background Health systems that deliver prevention of mother to child transmission (PMTCT) services in low and middle income countries continue to underperform, resulting in thousands of unnecessary HIV infections of newborns each year. We used a combination of approaches to health systems strengthening to reduce transmission of HIV from mother to infant in a multi-facility public health system in South Africa. Methodology/Principal Findings All primary care sites and specialized birthing centers in a resource constrained sub-district of Cape Metro District, South Africa, were enrolled in a quality improvement (QI) programme. All pregnant women receiving antenatal, intrapartum and postnatal infant care in the sub-district between January 2006 and March 2009 were included in the intervention that had a prototype-innovation phase and a rapid spread phase. System changes were introduced to help frontline healthcare workers to identify and improve performance gaps at each step of the PMTCT pathway. Improvement was facilitated and spread through the use of a Breakthrough Series Collaborative that accelerated learning and the spread of successful changes. Protocol changes and additional resources were introduced by provincial and municipal government. The proportion of HIV-exposed infants testing positive declined from 7.6% to 5%. Key intermediate PMTCT processes improved (antenatal AZT increased from 74% to 86%, PMTCT clients on HAART at the time of labour increased from 10% to 25%, intrapartum AZT increased from 43% to 84%, and postnatal HIV testing from 79% to 95%) compared to baseline. Conclusions/Significance System improvement methods, protocol changes and addition/reallocation of resources contributed to improved PMTCT processes and outcomes in a resource constrained setting. The intervention requires a clear design, leadership buy-in, building local capacity to use systems improvement methods, and a reliable data system. A systems improvement approach offers a much needed approach to rapidly improve under-performing PMTCT implementation programmes at scale in sub-Saharan Africa.

Hospital accreditation: lessons from low- and middle-income countries.

The growth of accreditation programs in low- and middle-income countries (LMICs) provides important examples of innovations in leadership, governance and mission which could be adopted in developed countries. While these accreditation programs in LMICs follow the basic structure and process of accreditation systems in the developed world, with written standards and an evaluation by independent surveyors, they differ in important ways. Their focus is primarily on improving overall care country-wide while supporting the weakest facilities. In the developed world accreditation efforts tend to focus on identifying the best institutions as those are typically the only ones who can meet stringent and difficult evaluative criteria.The Joint Learning Network for Universal Health Coverage (JLN), is an initiative launched in 2010 that enables policymakers aiming for UHC to learn from each other’s successes and failures. The JLN is primarily comprised of countries in the midst of implementing complex health financing reforms that involve an independent purchasing agency that buys care from a mix of public and private providers [Lancet 380: 933-943, 2012]. One of the concerns for participating countries has been how to preserve or improve quality during rapid expansion in coverage. Accreditation is one important mechanism available to countries to preserve or improve quality that is in common use in many LMICs today.This paper describes the results of a meeting of the JLN countries held in Bangkok in April of 2013, at which the current state of accreditation programs was discussed. During that meeting, a number of innovative approaches to accreditation in LMICs were identified, many of which, if adopted more broadly, might enhance health care quality and patient safety in the developed world.

Health Services Innovation: The Time Is Now

Biomedical innovation has improved prevention, diagnosis, and treatment resulting in reduction in mortality for most diseases. However, health and health care disparities remain across the lifespan because these advances have not been matched by advances in delivering care, patient engagement, adherence, or access to these advanced care strategies. Clinicians interested in these failures have an opportunity to make health systems more effective by bringing their insights and creativity to developing innovations in care delivery.

Preventing Unintended Pregnancy: A Pediatric Opportunity

* Abbreviations: IUD — : intrauterine device LARC — : long-acting reversible contraceptive Prevention is the cornerstone of pediatric practice, with immunization the prototype strategy because of its significant effectiveness in preventing selected infections. Other targets of prevention such as obesity, injuries, birth defects, and drug and alcohol use are important but lack simple, evidence-based, and equally effective strategies. We suggest that in response to the improvement in the effectiveness and safety of long-acting reversible contraceptives (LARCs; eg, intrauterine devices [IUDs], contraceptive implants), pediatricians have a special opportunity to prevent unintended pregnancy, not only in adolescents but in all women of childbearing age who bring their children into our offices for pediatric care. This commentary provides information about unintended pregnancy and the safety and effectiveness of LARC methods. We suggest specific opportunities for pediatricians to engage and motivate women to actively choose their reproductive futures and when to have their children. One-half of the 6.7 million pregnancies in the United States each year are unintended, 43% of which end in abortion.1 Although the studies have limitations, the data show that unintended live births suffer a disproportionately high rate of maternal and infant health problems, interfere with young mothers completing their education, and reduce the financial and emotional resources available to support and nurture existing children.2 The cost for births resulting from unintended pregnancies was estimated to be

Crossing the quality chasm in resource-limited settings.

11.1 billion in 2006.3 LARC methods are the most effective, safest, and most cost-effective reversible options to prevent unintended pregnancy. The 2 US Food and Drug Administration–approved methods (IUDs and the contraceptive implant) have higher efficacy rates compared with other reversible methods. The typical success rates during the first year of use are … Address correspondence to Barry Zuckerman, MD, Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, 771 Albany St, Dowling Building, 3rd Floor, Boston, MA 02118. E-mail: barry.zuckerman{at}bmc.org

Inpatient mortality of HIV-infected adults in sub-Saharan Africa and possible interventions: a mixed methods review

Over the last decade, extensive scientific and policy innovations have begun to reduce the “quality chasm” - the gulf between best practices and actual implementation that exists in resource-rich medical settings. While limited data exist, this chasm is likely to be equally acute and deadly in resource-limited areas. While health systems have begun to be scaled up in impoverished areas, scale-up is just the foundation necessary to deliver effective healthcare to the poor. This perspective piece describes a vision for a global quality improvement movement in resource-limited areas. The following action items are a first step toward achieving this vision: 1) revise global health investment mechanisms to value quality; 2) enhance human resources for improving health systems quality; 3) scale up data capacity; 4) deepen community accountability and engagement initiatives; 5) implement evidence-based quality improvement programs; 6) develop an implementation science research agenda.

Improving health system quality in low- and middle-income countries that are expanding health coverage: a framework for insurance.

BackgroundDespite the increased availability of anti-retroviral therapy, in-hospital HIV mortality remains high in sub-Saharan Africa. Reports from Senegal, Malawi, and Tanzania show rates of in-hospital, HIV-related mortality ranging from 24.2% to 44%. This mixed methods review explored the potential causes of preventable in-hospital mortality associated with HIV infections in sub-Saharan Africa in the anti-retroviral era.ResultsBased on our experience as healthcare providers in Africa and a review of the literature we identified 5 health systems failures which may cause preventable in-hospital mortality, including: 1) late presentation of HIV cases, 2) low rates of in-hospital HIV testing, 3) poor laboratory capacity which limits CD4 T-cell testing and the diagnosis of opportunistic infections, 4) delay in initiation of anti-retroviral therapy in-hospital, and 5) problems associated with loss to follow-up upon discharge from hospital.ConclusionOur findings, together with the current available literature, should be used to develop practical interventions that can be implemented to reduce in-hospital mortality.

The Age‐Friendly Health System Imperative

PURPOSE Low- and middle-income countries are increasingly pursuing health financing reforms aimed at achieving universal health coverage. As these countries rapidly expand access to care, overburdened health systems may fail to deliver high-quality care, resulting in poor health outcomes. Public insurers responsible for financing coverage expansions have the financial leverage to influence the quality of care and can benefit from guidance to execute a cohesive health-care quality strategy. DATA SOURCES and selection Following a literature review, we used a cascading expert consultation and validation process to develop a conceptual framework for insurance-driven quality improvements in health care. RESULTS OF DATA SYNTHESIS The framework presents the strategies available to insurers to influence the quality of care within three domains: ensuring a basic standard of quality, motivating providers and professionals to improve, and activating patient and public demand for quality. By being sensitive to the local context, building will among key stakeholders and selecting context-appropriate ideas for improvement, insurers can influence the quality through four possible mechanisms: selective contracting; provider payment systems; benefit package design and investments in systems, patients and providers. CONCLUSION This framework is a resource for public insurers that are responsible for rapidly expanding access to care, as it places the mechanisms that insurers directly control within the context of broader strategies of improving health-care quality. The framework bridges the existing gap in the literature between broad frameworks for strategy design for system improvement and narrower discussions of the technical methods by which payers directly influence the quality.

A case report of evaluating a large-scale health systems improvement project in an uncontrolled setting: a quality improvement initiative in KwaZulu-Natal, South Africa

The unprecedented changes happening in the American healthcare system have many on high alert as they try to anticipate legislative actions. Significant efforts to move from volume to value, along with changing incentives and alternative payment models, will affect practice and the health system budget. In tandem, growth in the population aged 65 and older is celebratory and daunting. The John A. Hartford Foundation is partnering with the Institute for Healthcare Improvement to envision an age‐friendly health system of the future. Our current prototyping for new ways of addressing the complex and interrelated needs of older adults provides great promise for a more‐effective, patient‐directed, safer healthcare system. Proactive models that address potential health needs, prevent avoidable harms, and improve care of people with complex needs are essential. The robust engagement of family caregivers, along with an appreciation for the value of excellent communication across care settings, is at the heart of our work. Five early‐adopter health systems are testing the prototypes with continuous improvement efforts that will streamline and enhance our approach to geriatric care.

Eliminating Mother-To-Child HIV Transmission Will Require Major Improvements In Maternal And Child Health Services

Objective New approaches are needed to evaluate quality improvement (QI) within large-scale public health efforts. This case report details challenges to large-scale QI evaluation, and proposes solutions relying on adaptive study design. Study design We used two sequential evaluative methods to study a QI effort to improve delivery of HIV preventive care in public health facilities in three districts in KwaZulu-Natal, South Africa, over a 3-year period. We initially used a cluster randomised controlled trial (RCT) design. Principal findings During the RCT study period, tensions arose between intervention implementation and evaluation design due to loss of integrity of the randomisation unit over time, pressure to implement changes across the randomisation unit boundaries, and use of administrative rather than functional structures for the randomisation. In response to this loss of design integrity, we switched to a more flexible intervention design and a mixed-methods quasiexperimental evaluation relying on both a qualitative analysis and an interrupted time series quantitative analysis. Conclusions Cluster RCT designs may not be optimal for evaluating complex interventions to improve implementation in uncontrolled ‘real world’ settings. More flexible, context-sensitive evaluation designs offer a better balance of the need to adjust the intervention during the evaluation to meet implementation challenges while providing the data required to evaluate effectiveness. Our case study involved HIV care in a resource-limited setting, but these issues likely apply to complex improvement interventions in other settings.