Zoe Dettrick

Do strategies to improve quality of maternal and child health care in lower and middle income countries lead to improved outcomes? A review of the evidence

Objectives Efforts to scale-up maternal and child health services in lower and middle income countries will fail if services delivered are not of good quality. Although there is evidence of strategies to increase the quality of health services, less is known about the way these strategies affect health system goals and outcomes. We conducted a systematic review of the literature to examine this relationship. Methods We undertook a search of MEDLINE, SCOPUS and CINAHL databases, limiting the results to studies including strategies specifically aimed at improving quality that also reported a measure of quality and at least one indicator related to health system outcomes. Variation in study methodologies prevented further quantitative analysis; instead we present a narrative review of the evidence. Findings Methodologically, the quality of evidence was poor, and dominated by studies of individual facilities. Studies relied heavily on service utilisation as a measure of strategy success, which did not always correspond to improved quality. The majority of studies targeted the competency of staff and adequacy of facilities. No strategies addressed distribution systems, public-private partnership or equity. Key themes identified were the conflict between perceptions of patients and clinical measures of quality and the need for holistic approaches to health system interventions. Conclusion Existing evidence linking quality improvement strategies to improved MNCH outcomes is extremely limited. Future research would benefit from the inclusion of more appropriate indicators and additional focus on non-facility determinants of health service quality such as health policy, supply distribution, community acceptability and equity of care.

Context-specific, evidence-based planning for scale-up of family planning services to increase progress to MDG 5: health systems research

BackgroundUnmet need for family planning is responsible for 7.4 million disability-adjusted life years and 30% of the maternity-related disease burden. An estimated 35% of births are unintended and some 200 million couples state a desire to delay pregnancy or cease fertility but are not using contraception. Unmet need is higher among the poorest, lesser educated, rural residents and women under 19 years. The barriers to, and successful strategies for, satisfying all demand for modern contraceptives are heavily influenced by context. Successfully overcoming this to increase the uptake of family planning is estimated to reduce the risk of maternal death by up to 58% as well as contribute to poverty reduction, women’s empowerment and educational, social and economic participation, national development and environmental protection.MethodsTo strengthen health systems for delivery of context-specific, equity-focused reproductive, maternal, newborn and child health services (RMNCH), the Investment Case study was applied in the Asia-Pacific region. Staff of local and central government and non-government organisations analysed data indicative of health service delivery through a supply–demand oriented framework to identify constraints to RMNCH scale-up. Planners developed contextualised strategies and the projected coverage increases were modelled for estimates of marginal impact on maternal mortality and costs over a five year period.ResultsIn Indonesia, Philippines and Nepal the constraints behind incomplete coverage of family planning services included: weaknesses in commodities logistic management; geographical inaccessibility; limitations in health worker skills and numbers; legislation; and religious and cultural ideologies. Planned activities included: streamlining supply systems; establishment of Community Health Teams for integrated RMNCH services; local recruitment of staff and refresher training; task-shifting; and follow-up cards. Modelling showed varying marginal impact and costs for each setting with potential for significant reductions in the maternal mortality rate; up to 28% (25.1-30.7) over five years, costing up to a marginal USD 1.34 (1.32-1.35) per capita in the first year.ConclusionLocal health planners are in a prime position to devise feasible context-specific activities to overcome constraints and increase met need for family planning to accelerate progress towards MDG 5.

Developing and costing local strategies to improve maternal and child health: the Investment Case Framework

Eliana Jimenez Soto and colleagues describe the Investment Case framework, a health systems research approach for planning and budgeting, and detail the implementation of the framework in four Asian countries to improve maternal, newborn and child health.

Trends in oral, pharyngeal and oesophageal cancer mortality in Australia: the comparative importance of tobacco, alcohol and other risk factors

Objective: The relationship of long‐term population‐level trends in oral, pharyngeal and oesophageal cancer mortality with major risk factors such as tobacco consumption have not been statistically analysed in Australia. We have demonstrated the long‐term implications using historical data.

100 years of mortality due to chronic obstructive pulmonary disease in Australia: the role of tobacco consumption

BACKGROUND Global studies of the long-term association between tobacco consumption and chronic obstructive pulmonary disease (COPD) have relied upon descriptions of trends. OBJECTIVES To statistically analyse the relationship of tobacco consumption with data on mortality due to COPD over the past 100 years in Australia. METHODS Tobacco consumption was reconstructed back to 1887. Log-linear Poisson regression models were used to analyse cumulative cohort and lagged time-specific smoking data and its relationship with COPD mortality. RESULTS Age-standardised COPD mortality, although likely misclassified with other diseases, decreased for males and females from 1907 until the start of the Second World War in contrast to steadily rising tobacco consumption. Thereafter, COPD mortality rose sharply in line with trends in smoking, peaking in the early 1970s for males and over 20 years later for females, before falling again. Regression models revealed both cumulative and time-specific tobacco consumption to be strongly predictive of COPD mortality, with a time lag of 15 years for males and 20 years for females. CONCLUSIONS Sharp falls in COPD mortality before the Second World War were unrelated to tobacco consumption. Smoking was the primary driver of post-War trends, and the success of anti-smoking campaigns has sharply reduced COPD mortality levels.

A Framework for the Economic Analysis of Data Collection Methods for Vital Statistics

Background Over recent years there has been a strong movement towards the improvement of vital statistics and other types of health data that inform evidence-based policies. Collecting such data is not cost free. To date there is no systematic framework to guide investment decisions on methods of data collection for vital statistics or health information in general. We developed a framework to systematically assess the comparative costs and outcomes/benefits of the various data methods for collecting vital statistics. Methodology The proposed framework is four-pronged and utilises two major economic approaches to systematically assess the available data collection methods: cost-effectiveness analysis and efficiency analysis. We built a stylised example of a hypothetical low-income country to perform a simulation exercise in order to illustrate an application of the framework. Findings Using simulated data, the results from the stylised example show that the rankings of the data collection methods are not affected by the use of either cost-effectiveness or efficiency analysis. However, the rankings are affected by how quantities are measured. Conclusion There have been several calls for global improvements in collecting useable data, including vital statistics, from health information systems to inform public health policies. Ours is the first study that proposes a systematic framework to assist countries undertake an economic evaluation of DCMs. Despite numerous challenges, we demonstrate that a systematic assessment of outputs and costs of DCMs is not only necessary, but also feasible. The proposed framework is general enough to be easily extended to other areas of health information.

Tobacco consumption and pancreatic cancer mortality: what can we conclude from historical data in Australia?

BACKGROUND Tobacco consumption is an established risk factor for pancreatic cancer yet studies of long-term mortality trends have not statistically analysed this relationship. We sought evidence for this relationship based on an analysis of long-term population-level data in Australia. METHODS Pancreatic cancer mortality data from 1931, tobacco consumption data and fruit and vegetable consumption data for Australia were utilized. Log-linear Poisson regression models were used to analyse pancreatic cancer mortality from 1931 with cumulative cohort and lagged time-specific tobacco consumption data and fruit and vegetable consumption data. RESULTS Pancreatic cancer mortality rose steadily for males until it began falling from the 1970s, and continued rising for females until 2006. These trends correspond with a long-term rise in male tobacco consumption until the 1960s and a later peak for females. Our models show that cumulative tobacco consumption predicts pancreatic cancer mortality for both sexes but with time lags only being significant for males. Fruit and vegetable consumption provides a protective effect against mortality in some of the models. CONCLUSION The success of smoking reduction programmes in Australia has contributed to the decline in pancreatic cancer mortality for males, providing important evidence about the need for tobacco control measures in populations where it is still increasing. Continued declines in female tobacco consumption should lead to a reversal of the long-term rise in female pancreatic cancer mortality.

Measuring Quality of Maternal and Newborn Care in Developing Countries Using Demographic and Health Surveys.

Background One of the greatest obstacles facing efforts to address quality of care in low and middle income countries is the absence of relevant and reliable data. This article proposes a methodology for creating a single “Quality Index” (QI) representing quality of maternal and neonatal health care based upon data collected as part of the Demographic and Health Survey (DHS) program. Methods Using the 2012 Indonesian Demographic and Health Survey dataset, indicators of quality of care were identified based on the recommended guidelines outlined in the WHO Integrated Management of Pregnancy and Childbirth. Two sets of indicators were created; one set only including indicators available in the standard DHS questionnaire and the other including all indicators identified in the Indonesian dataset. For each indicator set composite indices were created using Principal Components Analysis and a modified form of Equal Weighting. These indices were tested for internal coherence and robustness, as well as their comparability with each other. Finally a single QI was chosen to explore the variation in index scores across a number of known equity markers in Indonesia including wealth, urban rural status and geographical region. Results The process of creating quality indexes from standard DHS data was proven to be feasible, and initial results from Indonesia indicate particular disparities in the quality of care received by the poor as well as those living in outlying regions. Conclusions The QI represents an important step forward in efforts to understand, measure and improve quality of MNCH care in developing countries.

Informing family planning research priorities: a perspective from the front line in Asia.

Impressive reductions of up to 29% in maternal deaths may be expected from satisfying unmet need for contraception as shown in a recent analysis covering 172 countries (Ahmed et al. 2012). Despite the cost-effectiveness of family planning (Prata et al. 2010) investments remain low (Osotimehin 2012) a concern declared under Goal 5 on the UN Millennium Development Goals website ‘Inadequate funding for family planning is a major failure in fulfilling commitments to improving women’s reproductive health.’ Alongside investment and political commitment clear indicators for the coverage and quality of family planning services are required to design and implement strategies to improve family planning. However the evidence used in planning and monitoring of family planning is often suboptimal and poses a serious problem for effective efficient responses to scale up these services. The 2012 London Summit on Family Planning signalled renewed interest in this important intervention by the global community. Large investments were pledged and ambitious targets of access to contraception for 120 million women and girls by 2020 were set. This has also prompted the Alliance for Reproductive Maternal and Newborn Health to work with WHO and development partners to facilitate a prioritisation of the family planning research agenda. With a view to informing these discussions we were commissioned by the Australian Agency for International Development (AusAID) to identify the key knowledge gaps for evidence-based planning and budgeting for family planning. As part of a multicountry initiative working with policy makers to effect a more rational use of resources for reproductive maternal newborn and child health (Jimenez-Soto et al. 2012) we collated the data necessary to inform local decision-making on scaling up family planning services. Our work highlighted major evidence gaps that have the potential to undermine efforts to plan and invest in family planning and interfere with monitoring progress. The seven leading knowledge gaps identified are outlined in this short paper and provide an essential ‘front-line’ perspective to inform research priorities for effective scaling-up of family planning. We draw on examples from our study sites in four countries: two districts and two cities in Indonesia two provinces and one city in the Philippines three clusters of districts in Nepal two districts in the Indian state of Orissa and two districts in the state of Uttar Pradesh. We believe that this view from the front line provides a much-needed link between global agendas and the realities of implementation at a local level. (excerpt)