Rohit Ramaswamy

Development and piloting of a plan for integrating mental health in primary care in Sehore district, Madhya Pradesh, India.

Background The large treatment gap for mental disorders in India underlines the need for integration of mental health in primary care. Aims To operationalise the delivery of the World Health Organization Mental Health Gap Action Plan interventions for priority mental disorders and to design an integrated mental healthcare plan (MHCP) comprising packages of care for primary healthcare in one district. Method Mixed methods were used including theory of change workshops, qualitative research to develop the MHCP and piloting of specific packages of care in a single facility. Results The MHCP comprises three enabling packages: programme management, capacity building and community mobilisation; and four service delivery packages: awareness for mental disorders, identification, treatment and recovery. Challenges were encountered in training primary care workers to improve identification and treatment. Conclusions There are a number of challenges to integrating mental health into primary care, which can be addressed through the injection of new resources and collaborative care models.

Evidence-Based Interventions Are Necessary but Not Sufficient for Achieving Outcomes in Each Setting in a Complex World Empowerment Evaluation, Getting To Outcomes, and Demonstrating Accountability

Many evaluations of programs tend to show few outcomes. One solution to this has been an increasing prominence of the movement that requires programs to implement evidence-based interventions (EBIs). But in a complex world with complex organizations and complex interventions, many challenges have arisen to the implementation of EBIs with fidelity to achieve outcomes at scale. This includes challenges to achieving outcomes in each setting. In this article, we propose the use of empowerment evaluation and one of its major approaches (Getting To Outcomes [GTO]) as a promising method to address the challenges, and GTO can help organizations achieve outcomes by leading them through a set of “accountability questions” for implementing EBIs in their particular setting. These questions can be asked at multiple levels (e.g., national, state, and local organizations) responsible for achieving outcomes. Although we illustrate the possibilities with examples from health care and public health, the potential strategies can be applied to many areas of health and human services and education.

Global health partnerships: building multi- national collaborations to achieve lasting improvements in maternal and neonatal health

BackgroundIn response to health care challenges worldwide, extensive funding has been channeled to the world’s most vulnerable health systems. Funding alone is not sufficient to address the complex issues and challenges plaguing these health systems. To see lasting improvement in maternal and infant health outcomes in the developing world, a global commitment to the sharing of knowledge and resources through international partnerships is critical. But partnerships that merely introduce western medical techniques and protocols to low resource settings, without heeding the local contexts, are misguided and unsustainable. Forming partnerships with mutual respect, shared vision, and collaborative effort is needed to ensure that all parties, irrespective of whether they belong to resource rich or resource poor settings, learn from each other so that meaningful and sustained system strengthening can take place.MethodsIn this paper, we describe the partnership building model of an international NGO, Kybele, which is committed to achieving childbirth safety through sustained partnerships in low resource settings. The Kybele model adapts generic stages of successful partnerships documented in the literature to four principles relevant to Kybele’s work. A multiple-case study approach is used to demonstrate how the model is applied in different country settings.ResultsThe four principle of Kybele’s partnership model are robust drivers of successful partnerships in diverse country settings.ConclusionsMuch has been written about the need for multi-country partnerships to achieve sustainable outcomes in global health, but few papers in the literature describe how this has been achieved in practice. A strong champion, support and engagement of stakeholders, co-creation of solutions with partners, and involvement of partners in the delivery of solutions are all requirements for successful and sustained partnerships.

Evaluating Mobile Survey Tools (MSTs) for Field-Level Monitoring and Data Collection: Development of a Novel Evaluation Framework, and Application to MSTs for Rural Water and Sanitation Monitoring

Information and communications technologies (ICTs) such as mobile survey tools (MSTs) can facilitate field-level data collection to drive improvements in national and international development programs. MSTs allow users to gather and transmit field data in real time, standardize data storage and management, automate routine analyses, and visualize data. Dozens of diverse MST options are available, and users may struggle to select suitable options. We developed a systematic MST Evaluation Framework (EF), based on International Organization for Standardization/International Electrotechnical Commission (ISO/IEC) software quality modeling standards, to objectively assess MSTs and assist program implementers in identifying suitable MST options. The EF is applicable to MSTs for a broad variety of applications. We also conducted an MST user survey to elucidate needs and priorities of current MST users. Finally, the EF was used to assess seven MSTs currently used for water and sanitation monitoring, as a validation exercise. The results suggest that the EF is a promising method for evaluating MSTs.

Integrating empowerment evaluation and quality improvement to achieve healthcare improvement outcomes

While the body of evidence-based healthcare interventions grows, the ability of health systems to deliver these interventions effectively and efficiently lags behind. Quality improvement approaches, such as the model for improvement, have demonstrated some success in healthcare but their impact has been lessened by implementation challenges. To help address these challenges, we describe the empowerment evaluation approach that has been developed by programme evaluators and a method for its application (Getting To Outcomes (GTO)). We then describe how GTO can be used to implement healthcare interventions. An illustrative healthcare quality improvement example that compares the model for improvement and the GTO method for reducing hospital admissions through improved diabetes care is described. We conclude with suggestions for integrating GTO and the model for improvement.

Transforming Maternal and Neonatal Outcomes in Tertiary Hospitals in Ghana: An Integrated Approach for Systems Change

OBJECTIVE In Ghana, regional referral facilities by design receive a disproportionate number of high-risk obstetric and neonatal cases and therefore have mortality rates higher than the national average. High volumes and case complexity result in these facilities experiencing unique clinical, operational, and leadership challenges. In order to improve outcomes in these settings, an integrated approach to strengthen the overall system is needed. METHODS Clinical skills strengthening, quality improvement training, and leadership skill building have all been used to improve maternal and neonatal outcomes with some degree of success. We present here a customized model tailored to the particular context of tertiary referral hospitals that develops these three skills simultaneously, so that the complex interaction between clinical conditions, resource constraints, and organizational issues that affect the lives of mothers and babies can be considered together. This model uses local data to identify the drivers of poor maternal and neonatal outcomes and creates an integrated training package to focus on approaches to addressing these drivers. Based on this training, quality improvement projects are introduced to change the appropriate clinical or operational processes, or to strengthen organizational leadership. RESULTS In testing in one of the largest referral hospitals in Ghana, the model has been well received and has improved performance in several cross-cutting areas affecting the quality of maternal and neonatal care, such as triage, patient flow, and NICU hand hygiene. CONCLUSION An integrated approach to systems strengthening in referral hospitals holds much promise for improving outcomes for mothers with high-risk pregnancies and babies in Ghana and in other low-resource settings.

Challenges for Transformation: A Situational Analysis of Mental Health Care Services in Sehore District, Madhya Pradesh

AbstractThe proportion of individuals with mental disorders receiving evidence based treatments in India is very small. In order to address this huge treatment gap, programme for improving mental health care is being implemented in Sehore district of Madhya Pradesh, India. The aim of this study was to complete the situational analysis consisting of two parts; document review of Sehore district mental health programme followed by a qualitative study. The findings suggest that there are major health system challenges in developing and implementing the mental health care plan to be delivered through primary health care system in Sehore district.

The cost effectiveness of a quality improvement program to reduce maternal and fetal mortality in a regional referral hospital in Accra, Ghana

Objective To evaluate the cost-effectiveness of a quality improvement intervention aimed at reducing maternal and fetal mortality in Accra, Ghana. Design Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. Methods Data were collected on the cost and outcomes of a 5-year Kybele-Ghana Health Service Quality Improvement (QI) intervention conducted at Ridge Regional Hospital, a tertiary referral center in Accra, Ghana, focused on systems, personnel, and communication. Maternal deaths prevented were estimated comparing observed rates with counterfactual projections of maternal mortality and case-fatality rates for hypertensive disorders of pregnancy and obstetric hemorrhage. Stillbirths prevented were estimated based on counterfactual estimates of stillbirth rates. Cost-effectiveness was then calculated using estimated disability-adjusted life years averted and subjected to Monte Carlo and one-way sensitivity analyses to test the importance of assumptions inherent in the calculations. Main outcome measure Incremental Cost-effectiveness ratio (ICER), which represents the cost per disability-adjusted life-year (DALY) averted by the intervention compared to a model counterfactual. Results From 2007–2011, 39,234 deliveries were affected by the QI intervention implemented at Ridge Regional Hospital. The total budget for the program was

Unpacking the black box of improvement

2,363,100. Based on program estimates, 236 (±5) maternal deaths and 129 (±13) intrapartum stillbirths were averted (14,876 DALYs), implying an ICER of

Strengthening decentralized primary healthcare planning in Nigeria using a quality improvement model: how contexts and actors affect implementation

158 (