Skip to 0 minutes and 9 seconds WENDY GRAHAM: The purpose of this step is to enable learners to gain an understanding of what quality of care is and why it’s important. There are two parts to this step. The first is focusing on the supply of health services and care and the second on the experience and demand of care. The importance of the quality of care for survival and health of new mothers and babies has actually been known about for centuries. By quality here we mean the caring environment. For example, that seen in this picture which is the Glasgow Royal Maternity Hospital in Scotland at the turn of the 20th century.
Skip to 0 minutes and 41 seconds And this is an important time in history when the risk of a mother dying of childbirth was actually four times higher in the health facility compared to at home Quality not only means the environment but it also means the practises of health care providers, such as good hygiene and infection prevention, as well as drug availability. And in this historic setting shown in this photograph , it was in fact poor understanding and practice of hygiene together with a lack of antibiotics which had not been discovered at this time. Those three elements together explain why maternal mortality was so high. So the maternal mortality was high in this context of poor quality of care in part because of poor understanding.
Skip to 1 minute and 19 seconds So clearly, quality matters. Despite the long standing evidence based on the importance of quality in the context of low- and middle- income countries, attention to quality versus coverage of care has been quite recent. The focus of many national and international initiatives in low- and middle- income countries has been on achieving high levels of provision and uptake along the continuum of care– the continuum of care as shown in this graph taken from the initiative Countdown to 2015. This graphs shows a wide range of coverage of interventions across 68 countries from a very low coverage of 8% of pregnant women receiving anti-malarials to 85% of children across the 68 countries receiving vitamin A.
Skip to 2 minutes and 1 second But of course, this average picture which is pooling data across 68 countries actually masks wide disparities in the uptake of care between countries and within countries– for example, the uptake between rich and poor women. But the other thing that is masked by just focusing on coverage is it doesn’t tell us about the quality of the care. It tells you that women went and received, for example, skilled attendants at delivery, but coverage alone does not tell you the adequacy of the care. Similarly for something like antenatal care, we see that women are receiving four visits, but the content, the quality of the follow-up visits is not covered when you consider just the uptake of care.
Skip to 2 minutes and 39 seconds There is however now a stronger recognition of the importance of quality as well as coverage, and this is seen in this quote taken from the Countdown to 2015 Initiative. Nevertheless at the moment, routine data on quality still lags behind what we have on coverage. One of the reasons for that is that quality is a multidimensional concept as we’ll come to quite shortly. But the reason why quality has hit the agenda is there are several reasons driving that, but not the least of which is the fact that many countries are no going to achieve by the end of 2015, MDG 4 in child mortality, or MDG 5 on maternal mortality.
Skip to 3 minutes and 14 seconds This has encouraged countries to reexamine how this can have happened, how the outcomes have not been achieved and mortality hasn’t been reduced when in fact coverage has increased. And as you’ll see from the next slide, this shows you one of the rather enigmatic pictures that we find. Quality is crucial to better health and reduced mortality. And in the absence of quality improvement, progress and important outcomes like mortality will be limited. What happens is we see that quality is on the critical pathway to achieving mortality reductions. And in the absence of quality, we end up with rather puzzling pictures, as for example seen in this graph.
Skip to 3 minutes and 52 seconds This graph is part of a recent paper showing you the levels of met need for emergency obstetric care as against the level of maternal mortality. And what it shows is a positive correlation– in other words, as the levels of emergency obstetric care coverage of emergency obstetric care increases, so maternal mortality levels are lower. But the relationship is not a perfect one, it’s not simple either. So for example, what you see are some countries achieve quite high coverage of emergency obstetric care– more than 40 or 50% levels of coverage– and yet maternal mortality remains high with maternal deaths of 400 per 100,000 live births– in other words, suggesting a mismatch.
Skip to 4 minutes and 34 seconds So in other words, although the coverage of emergency obstetric care is improving and in some cases quite high, the actual quality of that emergency obstetric care is questionable because we are seeing mortality is remaining high. So again, quality sits on the critical pathway to achieving good outcomes and reduced mortality. So how do we define the essential elements of quality of care? In this slide, it shows you the thinking of one of the fathers of quality of care. That’s a gentleman called Donabedian who in the early 1980s developed this very simple framework and he identified these three components.
Skip to 5 minutes and 13 seconds He said that quality comprised of the structure of the service, process of care, and the outcomes both in terms of patient’s health and mortality, as well as patient and provider satisfaction. However, others have going on to break those three elements down a little bit more and give them greater specificity. As you can see in this table from the work of Sima Berendes and colleagues, indeed now there are a very, very large number of definitions and frameworks on quality of care, but all basically highlight the fact that quality is a multi-dimensional concept and cannot be captured by single indicators nor single dimensions nor single ways of measuring it.
Skip to 5 minutes and 53 seconds The multi-dimensional nature of quality presents a challenge for low- and middle- income countries where routine health information systems are often weak and the capacity to capture rather complex issues like quality is also very challenged. Rethinking on quality of care and its measurement continues to this day throughout the world. But perhaps one of the most important developments occurred when the distinction was made between looking at the provision, or the supply of care, versus the experience of care. And we see this in the next slide. Here, the distinction is summarised. It’s pointing out that we need to look at both the quality of care in terms of the provision of care as well as the experience of care.
Skip to 6 minutes and 35 seconds And both of these are very important and we will use the point on the continuum of care around labour and delivery– a really crucial time for mothers and newborns– to examine in particular. In this particular step, we’re going to focus on the supply side or the provision of care. And subsequently, we’re going to move onto look at the experience of care, or the demand side. Firstly, let’s do some reflection on what we would expect of a facility that is providing or supplying care for women in childbirth.
Skip to 7 minutes and 3 seconds Just think for a minute and think of this question: what would you expect to be supplied by health facilities offering quality delivery care? Let’s examine the example of a physical infrastructure of a facility. I think all of us would think it’s very reasonable to expect that a building– the building itself where women are delivering– is fit for purpose, indeed welcoming, as we see here in this sign for the birthing facility in Ghana. And in this photograph, it also tells us something else about the importance of the building and it shows the water supply is also critical. In other words, physical resources of infrastructure, such as a building, is a core element of quality.
Skip to 7 minutes and 41 seconds The state of the building is important as are also issues like the utilities such as electricity, water and sanitation. So what exactly do we know about this aspect of quality, the supply of care in low- and middle- income countries? A short answer to this is that there’s not a huge amount known but it is growing. It is growing thanks to some standardised surveys that are being carried out as part of a link with a group that provide the Demographic and Health surveys or also undertake surveys called the Service Provision Assessments or SPAs.
Skip to 8 minutes and 11 seconds And through the SPAs, we found some really interesting and important findings about the state of infrastructure and what is available in terms of the supply of services in low- and middle- income countries. And in the next slide, we see some examples of findings from the survey in 2010 in Tanzania.
Skip to 8 minutes and 30 seconds What this shows you is the three different types of facilities: hospitals, health centres and dispensaries across Tanzania. It shows you to what extent these facilities were able to meet criteria for good water and sanitation, or what we call ‘WASH safe’. And what it actually shows you is the horizontal bar shows you the average across all the facilities in Tanzania or that less than half of all the facilities were ‘WASH safe’. In other words, they had adequate water and sanitation. But also the situation is seems to be worse in some parts of these facilities.
Skip to 9 minutes and 7 seconds So if you’ve got a particularly the dark blue bars, they just show you what the situation is in terms of water and sanitation specifically on the labour ward. And there we see the situation is in fact, worse. We see that less than a quarter of the labour wards were able to meet the criteria for good water supply and sanitation. And in fact, labour wards are areas in the facility that need to be working 24/7 and they are often very crowded and so issues like water and sanitation are absolutely key to maintaining basic hygiene standards for mothers and newborns. And it’s very difficult to imagine good quality care where water and sanitation and water facilities are very poor.
Skip to 9 minutes and 48 seconds So water in some ways is a very core part of quality. It’s a marker of quality. And it also has implications for other aspects of quality, for example in the next slide. In this slide, we see an example of the importance of water as an aspect of quality of care. What we see is a routine deep clean of the maternity ward being undertaken in a facility in West Africa. And this image reminds us that it’s not water that’s needed for cleaning, but also we need cleaners. We need staff that are trained with emergency support and motivation to carry out a good job. And those staff also need to have cleaning equipments.
Skip to 10 minutes and 24 seconds Now, of course cleaners are not front-line providers for women in labor, but their work, what they do, and to what extent they’re able to do their work well, to do good quality work, impacts on the physical state of the maternity ward. And even beyond cleaning, there are many any other issues that could relate to hygiene which act as markers of quality of care, which we can see in the next picture. In this slide, it shows a variety of images from the shortage of beds and the presence of floor patients. That’s a poor quality marker.
Skip to 10 minutes and 55 seconds It’s a marker of poor quality care– to the availability of gloves– if there were no gloves then it’s hard to see how care could be good quality– to issues of basic laboratories here– the laboratory is out on the veranda of the facility– to the availability of cleaning fluids such as bleach. Here we have plenty of bleach here, so good quality cleaning is possible. And the one image which is about the presence of animals on the maternity ward. Clearly, very few people would regard that as a good quality marker. So as this shows, this is showing very much the supply side of the health system. It’s showing you aspects of quality that relate to the provision of care.
Skip to 11 minutes and 34 seconds But I said earlier in slide eight that there’s another aspect of the quality of care is the demand side. So let’s go a little bit closer to looking at what we’re meaning by defining quality of care. Whether quality is on the supply side or the demand side, what do we actually mean by quality? And I said earlier that quality is a multi-dimensional issue, one of the problems has been that by emphasising too much this complexity on a multi-dimensional nature, sometimes this has acted as a deterrent to looking at quality. It’s been seen as too complex or too difficult to look at in some low-income countries.
Skip to 12 minutes and 9 seconds So if we go back to basics and look at one of the simplest and clearest definitions. I showed you earlier some more complicated definitions, the way that there are different dimensions. But we can actually end this piece of work by looking at one of the most basic definitions that actually helps us to understand both the demand and the supply side. And I put this together on the next slide with a very powerful image of quality, or rather poor quality. So here we see the very simple definition that was presented in 2009, which I feel succinctly reminds us of what matters.
Skip to 12 minutes and 45 seconds Quality care is care which is clinically effective, it’s safe and a good experience for the patients– in our case for mothers. Most of us as we look at this picture, would probably agree that this birthing table taken from a health facility in a low-income country shows us that, for example, this cannot surely be a good and acceptable experience for women in labour. A woman being asked to deliver on this table would surely be a marker of poor quality care. This cannot be acceptable to women, nor indeed to the health workers who are actually carrying out the care in this birthing room. So in some ways, this image is an image of poor quality of care.
Skip to 13 minutes and 24 seconds So in my final slide, I just tried to summarise the learning summary and from this particular step on quality of care. So firstly, we need to recognise that high & equitable coverage of care is necessary, but it’s not sufficient alone for ensuring that mothers and newborns survive and are healthy. Quality of care is also really crucial. Quality of care is now being given more attention at local and national levels in low- and middle-income countries stimulated in part by the fact that MDG4 and 5 targets, and mortality targets are not being achieved in many countries despite there being increases in service coverage.
Skip to 14 minutes and 1 second Quality of care has are many different dimensions and definitions, and so, for us indeed in the longer term, require multiple indicators and mixed methods. But you can also use issues like water and sanitation in health facilities as a way to help reveal some of the aspects of quality and so simplify the mission. And I’ve given you several examples of how you can use aspects around infrastructure, aspects around hygiene to try and throw a light on quality of care. One common definition of quality is that quality means that clinical effectiveness, safety and a good experience for the patient. And this emphasises the two crucial sides to quality– the supply or provision of care and the demand or experience of care.
Skip to 14 minutes and 42 seconds In the next step, I’m going on focus more on the demand or experience of care. Thank you.
Quality of care: supply side
With increases in the numbers of facility births during the MDG era, there is a need to draw more attention to quality of care. In this and the following step, Professor Wendy Graham from the London School of Hygiene & Tropical Medicine and the University of Aberdeen introduces the concept of quality of care, splitting the topic into supply and demand sides.
Here we focus on the supply of health services and care, thinking about not only the care environment and product availability, but the practices of health care providers, such as hygiene, internationally recognised good practices and management of emergencies. In the next step we move on to the demand side, or a woman’s experience of care.
Please note that this video was recorded remotely and the audio is different to other steps. If you have any issues with the sound please make use of the transcript.
© London School of Hygiene & Tropical Medicine