Quality, equity and dignity in health services delivery in the who African Region: bridging the quality gap to accelerate progress towards meeting the SDG targets for maternal, newborn and child health: report of the Secretariatt

AFR/RC70/9 7 July 2020 REGIONAL COMMITTEE FOR AFRICA Seventieth Session Virtual session, 25 August 2020 ORIGINAL: ENGLISH Provisional agenda item 12 QUALITY, EQUITY AND DIGNITY IN HEALTH SERVICES DELIVERY IN THE WHO AFRICAN REGION: BRIDGING THE QUALITY GAP TO ACCELERATE PROGRESS TOWARDS MEETING THE SDG TARGETS FOR MATERNAL, NEWBORN AND CHILD HEALTH Report of the Secretariat CONTENTS Paragraphs BACKGROUND ............................................................................................................................... 1–5 ISSUES AND CHALLENGES ....................................................................................................... 6–12 ACTIONS PROPOSED ................................................................................................................. 13–19 ANNEX Page QUALITY OF CARE FRAMEWORK ................................................................................................. 5 AFR/RC70/9 Page 1 BACKGROUND 1. In 2015, Member States endorsed the Global strategy for women’s, children’s and adolescents’ health 2016–2030 (GSWAC),1 committing to improve delivery of quality health services for mothers, newborns and children. Despite this global commitment, progress in the African Region remains inadequate. Two thirds of globally reported maternal deaths occur in the sub-Saharan African Region.2 Although some countries in the Region have commendable levels of skilled birth attendance, this has not translated into reductions in their maternal mortality ratio (MMR). It is estimated that about 61% of newborn deaths and half of maternal deaths are due to poor quality of care,3 a situation that is likely to be further aggravated by COVID-19 infection. 2. The Framework for universal health coverage (UHC)4 endorsed by Member States in 2017 places quality of care (QoC) at its core. This was reaffirmed in the 2019 high-level United Nations General Assembly meeting on UHC. Quality of care is the degree to which health services increase the likelihood of desired health outcomes and are consistent with care that is effective, safe and people-centred.5 3. In 2016, the World Health Organization (WHO) outlined a vision for QoC, where “every pregnant woman and newborn receives quality care throughout pregnancy, childbirth and the postnatal period”.6 The conceptual framework for its implementation encompasses improving both provision of care and the patient’s experience of care. The framework forms the basis of the 2016 maternal and newborn health (MNH) standards of care and the 2018 paediatrics quality standards, which define the minimum requirements for achieving high-quality intrapartum and paediatric care. (Annex) 4. In 2017, to operationalize the framework and the use of the standards, WHO, partners and the Governments of nine Member States7 (seven from the Region and two from the South-East Asia Region) created a partnership to accelerate the reduction of preventable maternal and newborn illness and deaths, and to improve every mother’s experience of care. This Network for Improving Quality of Care for MNCH (QoC Network) is now operational in nine Member States8 in the Region. These countries continue to be supported to implement quality improvement processes and mechanisms and in fostering learning that is now being replicated in other Member States. 5. This paper outlines the issues and challenges currently being faced in the Region in terms of the delivery of quality care to mothers, newborns and children. It also proposes priority actions for implementation during the period 2020–2025. 1 Every Woman Every Child: The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) 2015: 2 WHO: Trends in Maternal Mortality: 2000-2017, Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2019. 3 Kruk E. Margaret et al: Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. The Lancet DOI: (10.1016/S0140-6736(18)31668-4). 4 World Bank/JICA/The Global Fund/African Development Bank/WHO: Universal Health Coverage in Africa: A framework for action. 2016. 5 World Health Organization, Organisation for Economic Co-operation and Development, and The World Bank. Delivering quality health services: a global imperative for universal health coverage. 2018. 6 Tuncalp O, et al. Quality of care for pregnant women and newborns—the WHO vision. BJOG 2015; 122:1045–1049. 7 Bangladesh, Côte d’Ivoire, Ethiopia, Ghana, India, Malawi, Nigeria, Uganda, United Republic of Tanzania. 8 Côte d’Ivoire, Ethiopia, Ghana, Kenya, Malawi, Nigeria, Uganda, Sierra Leone, United Republic of Tanzania. AFR/RC70/9 Page 2 ISSUES AND CHALLENGES 6. Unclear national direction and governing framework on quality: Although 76% of the countries in the Region report having some relevant national policy on quality of care,9 the necessary structures needed for implementation are inadequate. A clearly articulated and explicit direction on quality is absent in most countries and even when present, it is often not implemented effectively at subnational level. In addition, there is poor coordination of ministry of health programmes, leading to fragmentation in service delivery. 7. Weak coordination and fragmentation of quality programmes: In many countries in the Region, there are multitudes of donor-supported projects that seek to improve the quality of care for maternal, newborn and child health (MNCH) services. In most cases, these programmes target the same districts, health facilities and health workers with little coordination, particularly when there is no national quality guidance. This lack of coordination creates a huge burden for the already overburdened health workers, it is not effective in the long run, and results in many pilot projects that countries are unable to scale up. 8. Weak health information systems: Effective planning for and implementation of quality improvement plans is hampered by weak health information systems (HIS). Data that are collected are incomplete and of poor quality, not consistently analysed, and often not used in decision-making. Experiences from implementation in the African Region10 show that the maternal, newborn and child health indicators that are collected in the HIS are more likely to measure availability, access or use of health services than the quality of care rendered. Indicators that capture users’ perspectives and experiences are even more rare. Where quality indicators exist, they are inconsistently defined, and rarely used for programme decision-making by health managers in facilities, or at district and national levels. 9. Inadequately prepared human resources for health and poor supportive environment for health providers: Currently no country in the Region has achieved the Sustainable Development Goal (SDG) index threshold of 4.45 doctors, nurses and midwives per 1000 population that is needed to achieve UHC.11 This results in overburdened health workers who are in most cases inequitably distributed and whose services may lead to suboptimal patient care as well as exposure to harm. For example, some reports show that adherence to clinical practice guidelines in eight low- and middle- income countries was below 50% in several instances, resulting in low-quality antenatal and child care and deficient family planning.6 Very few countries are investing in on-the-job support mechanisms to retain competencies, such as clinical mentoring or quality improvement coaching, to create a positive environment to support and motivate health workers 10. Absence of basic infrastructure in health facilities: Despite some progress seen in the Region, too many health facilities still do not meet minimum standards on infrastructure, water and sanitation or basic equipment, which are necessary for the provision of quality MNCH services. Only 51% of health care facilities have basic water services and 23% basic sanitation services.12 The 9 WHO AFRO: Reproductive, Maternal, Newborn, Child, and Adolescent Health Policy Survey. September 2019. 10 The eight Network Countries (Côte d’Ivoire, Ethiopia, Ghana, Malawi, Nigeria, Sierra Leone, Uganda and United Republic of Tanzania). 11 WHO: Health workforce requirements for universal health coverage and the sustainable development goals: Human resources for health observer series no 17, 2016. 12 WHO and UNICEF. WASH in health care facilities: Global Baseline Report 2019. AFR/RC70/9 Page 3 facilities which tend to meet these standards are likely to be hospitals and/or located in urban settings. 11. Inability of communities and individuals to claim their rights to quality care: Communities, especially clients of low socioeconomic status, are rarely aware of their rights to quality services and decisions concerning their care.13 This makes them unable to complain when poor-quality care has been provided. Women across the world experience disrespect, especially around childbirth, with younger and poorer women being more vulnerable to this abuse, suggesting inequality in service delivery.14 This inadequacy in demanding what is right also extends across health service provision, including how services are designed, organized, implemented and evaluated to address the needs and preferences of women and the wider community. 12. To ensure that every woman, newborn and child is treated with respect and their dignity and rights upheld when receiving care, the following priority actions are proposed for Member States with the support of WHO and partners. These will facilitate governments’ ownership and institutionalization of quality of care for mothers and children through contextualizing the global MNCH standards. ACTIONS PROPOSED 13. Ensuring government leadership, ownership and institutionalization of QoC in MNCH health services. (a) Setting national direction on quality. There is a need to ensure dialogue towards the development of policies and strategies that address social health determinant that impact on quality of care. A national direction on quality should drive implementation at subnational, facility and community levels with strong feedback to the national level. This should include outlining a governance structure, coordination mechanisms and strong regulatory systems to facilitate institutionalization of quality of care in both private and public health facilities, including for MNCH and other programmes and avoidance of fragmentation or exclusion of quality of care programmes. (b) Committing to and strengthening coordination of actions of relevant sectors for joint accountability for results. Ensuring leadership and coordinated multisectoral engagement with all stakeholders working in QoC is key. This includes guaranteeing that all partners report on the agreed global indicators for quality of care as the minimum and coordinate their reporting by all stakeholders. 14. Providing standard operating procedures (SOPs) and tools based on the WHO MNH and paediatric care standards. Member States should ensure availability of capacity for the implementation of the MNCH QoC standards in a comprehensive, integrated and equitable manner that reflects the WHO vision of quality of care. They should review and adapt the standards to make them more context-specific and integrate them into already ongoing national QoC programmes in the country. 13 ME Kruk, AD Gage, C Arsenault, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health (2018). http://dx.doi.org/10.1016/S2214-109X(18)30386-3. 14 Bohren A. Meghan et al: How women are treated during facility-based child birth in four countries: a cross sectional study with labour observations and community-based surveys lancet, October 2019. AFR/RC70/9 Page 4 15. Strengthening health information systems and using evidence on quality and patient/client experiences for decision-making and for prioritizing actions. Member States should strengthen local data systems, including putting in place tools and processes to improve the quality of data produced and increasing their use for tracking quality improvement processes and patient outcomes. While the number of measures collected in the health information system needs to be reduced, ministries of health need to include indicators that measure quality of care as these are often not collected. They should also invest in field testing and rolling out patient-reported measures for inclusion in the routinely reported data, and in research and specific surveys to support evidence generation. 16. Creating an enabling environment for health workers. As outlined in the document AFR/RC67/11 on HRH (30 August 2017),15 in supporting and implementing policies that increase and incentivize health worker performance, Member States should ensure that the work environment is friendly and motivating, and that health workers have the right competencies to deliver good quality MNCH care. In addition, Member States should sensitize health care workers on their roles and responsibilities in the provision of quality care to ensure respect for clients’ rights and dignity. They should review their human resources for health strategies to ensure they address human resource gaps and distribution (urban and rural) to reduce inequities. Furthermore, they should review and update the training curricula to ensure the provision of on-site training, peer reviews and supervision to enhance competencies, and make available opportunities for continuous professional development, including taking advantage of new and innovative digital technologies that facilitate continued professional learning. Dissemination of best practices should be an additional measure to strengthen the quality of care in countries. 17. Ensuring that health facilities have the right infrastructure for the configuration of MNCH services expected at their level. Water and sanitation facilities and equipment that meet the minimum standards in providing quality maternal, newborn and child health services should be the norm. While this is still a challenge in many settings, these minimum standards can be maintained and improved through regular assessments using the WHO MNCH quality of care standards. 18. Empowering communities and individuals to enable them to claim their rights to quality care at all levels of the health system. Governments and partners should seek to ensure that countries adopt and implement the seven domains outlined in the White Ribbon Alliance’s Respectful Maternity Care Charter16 which clarifies and clearly articulates the rights of women and newborns when they are receiving maternity care within a health care facility. They should put special emphasis on respectful and dignified care and the right to information. They should also ensure inclusion of community representatives during the development and implementation of QoC policies or strategies which should include putting in place mechanisms for users to provide feedback on the quality of health services they receive. 19. The Regional Committee is hereby requested to consider and endorse the proposed actions. 15 AFR/RC67/11: The African Regional Framework for the Implementation of the Global Strategy on Human Resources for Health: Workforce 2030. 16 White Ribbon Alliance: Respectful Maternity Care Charter: Universal Rights of Mothers and Newborns. AFR/RC70/9 Page 5 Annex: Quality of care Framework