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Zambia Health Systems Strengthening Case Study

In 2019 I spent six months as an Improving Global Health Fellow with the Quality Directorate at Zambia's Ministry of Health. This abstract was published in the conference abstract book that year. It reports what implementing partners and health professionals said about how they contribute to quality improvement, and the enablers and barriers they described.

Lynch, M. (2019) Creating a Quality Improvement Culture for Zambia. Published in the abstract book of Zambia's Quality Improvement Conference: Excellence and Innovation Towards Universal Health Coverage, p. 36. Health Education England and Zambia, Ministry of Health.

Background

Zambia's Health Strategy (MoH 2016) defines the health priorities and plans to meet the Sustainable Development Goals which will enable Zambia to reach Vision 2030. Plans outline how healthcare will be delivered and the National Quality Road Map defines the steps to improve health care and population health. This 'call to action' coordinates the impact of and quality of healthcare. To be contextually and clinically appropriate it is coproduced by those involved in delivery and use of healthcare.

Methods

A literature review identified evidence on design and impact of healthcare Quality Road Maps and Zambian publications on health challenges, campaigns and improvements in quality (Mutale 2015, USAID 2018). System reviews (Berwick 2018) suggest a need to understand the cost, complexity and culture of health care as well as the clinical need and context of delivery. Building on these findings and the WHO (2018) quality strategy a 2019 Zambian stakeholder analysis explored this complexity and culture to ascertain implementing partners' and health professionals' thoughts on how they are contributing to, or not contributing to, quality improvement. This has provided insights into the enablers and barriers to quality improvement.

Results

Analysis and synthesis of the interviews identified culture as a common theme. The findings are presented using a Cultural Web Quality Improvement Tool (Johnson and Scholes 1997). This shows current philosophical approaches to health system strengthening, national health organisation design, power symbols, stories told and hoped for future approaches to a coordinated quality approach.

Conclusions

The Cultural Web content highlights quality aspects that have not been possible to articulate in previous stakeholder analysis, situation analysis or quality reports. It makes enabling and disabling issues that were invisible visible. Culture is key to any system improvement. By working with system leaders, health care professionals, collaborating partners and patients we identify what a quality culture is and the steps needed to reach it. Quality is therefore co produced, contextually and culturally appropriate and sustainable.

Recommendations

  • Expand quality measures beyond what is currently counted to include the culture and climate of healthcare systems.
  • Develop education and support systems to enable partners, professionals and patients to identify and act to improve organisational culture.
  • Create systems to communicate national priorities and plans and collaborate on approaches to ensure quality is improved and improvements are sustained.

References

Berwick, D. (2018) Three Global Health-Care Quality Reports in 2018. The Lancet, 392(10143), 194-195. thelancet.com

Johnson, G. and Scholes, K. (1997) Exploring Corporate Strategy. London: Financial Times Prentice Hall.

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PAST WORK · PUBLICATION

Integrating Community Outreach into Quality Improvement to Promote Maternal and Child Health: A Case Study of Shampande Urban Clinic and Choma General Hospital (1st Level) 2019

Mwamulela Webby1, Lynch, Marion2, Bickham, David3, Mukasa, Emmanuel4, Banda, Emmanuel5, Barrett, Katie (2019). Published in the abstract book of Zambia's Quality Improvement Conference: Excellence and Innovation Towards Universal Health Coverage, p. 85. 1. Ministry of Health-Choma District-Shampande urban clinic; 2. Health Education England and Ministry of Health Zambia; 3. Boston Children's Hospital Center for Media and Child Health; 4. Office of the President; 5. UNDP.

I co-authored this abstract with Mr Mwamulela Webby of Shampande Urban Clinic and colleagues, and it was published in the abstract book of Zambia's Quality Improvement Conference in 2019. It describes how community outreach was integrated with facility-based quality improvement to support maternal and child health in Choma District.

Introduction

Riley (2010) defined QI in the context of public health as "a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community". This definition reflects how QI can be applied to individual facilities such as hospitals and clinics, as well as larger health systems.

The current research was carried through a mixed methods case study to examine how community outreach is integrated into facility-based QI & QC approaches aimed to assist Zambia's health system to accelerate the achievement of Sustainable Development Goal (SDG) #3 (good health and well-being) which ensures healthy lives and promote wellbeing at all ages including massive promotion of maternal and child health by 2030.

Methods

A descriptive, cross sectional study utilizing a mixed methods approach was used to elicit study participants' accounts of how community outreach strategies were integrated with QI processes at their facilities. I purposively sampled 2 facility-based QI teams as cases based on inputs from QIQC committees (1 team from the 1st level hospital and 1 team from the clinic). Each case study included individual interviews with QI team members (e.g. general health nurses, midwives, and health facility incharges) and facility observations. A single QI team could represent 1 facility, in the case of 1st level hospital, and/or several facilities, in the case of urban sub clinics. To obtain information from teams whose members experienced different levels of exposure to QI principles, we purposively selected QI team members who had participated in the QIQC Training as well as those who had not had any formal exposure to QIQC methodology. The total sample included 33 interviews, ranging from 3 to 6 per team through convenience sampling. Collected data sets were analyzed by SPSS-16 software.

Results

Findings from a quantitative evaluation of wave one demonstrated a decrease in mean mortality from the pre-intervention to post-intervention periods for neonates (2.5/1000 to 0.9/1000) and infants (3.5/1000 to 2.4/1000), as well as an increase in mean skilled delivery (55.9 to 64.7%). These statistics are descriptive presentations of the mean in outcomes from pre to post intervention phases. QI teams could also assess whether there were noticeable increases in health services use (e.g. attendance at a clinic) among women and children in the targeted communities following community-level outreach efforts. Participants explained that QI data monitoring enabled them to further refine community outreach efforts to locations with higher maternal and infant mortality, and lower rates of health services use.

Conclusion

The findings indicated how QI teams used community outreach as a key component of the study. By conceptualizing communities as key drivers of QI&QC outcomes when the exercise was designed, a space was created for integrating community outreach activities together with facility-based activities. The strategies described in this paper reflect the importance of involving communities in QI efforts to improve maternal and child health outcomes.

Recommendations

  1. There should be a massive training for all health staff, including community liaison in QAQI as this can provide a wider understanding of the linkage between QI efforts and community engagement.
  2. QA&QI case studies (research) should be highly promoted and motivated through incentives in the form of financial aid and other necessities, as this exercise is so costly in facilitating all logistics involved.

References

Riley, W.J., Moran, J.W., Corso, L.C., Beitsch, L.M., Bialek, R. and Cofsky, A. (2010) Defining quality improvement in public health. Journal of Public Health Management and Practice, 16(1), 5-7. pubmed.ncbi.nlm.nih.gov

Zambia's Quality Improvement Conference (2019) Excellence and Innovation Towards Universal Health Coverage. National Health Research Authority. nhra.org.zm Abstract book, p. 85 (PDF): Abstract Book