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Quality of care: demand side

Listen to Professor Wendy Graham discuss the demand side, or experience, of quality of care.
WENDY GRAHAM: I’m going to speak in this step of the course about quality of maternal and newborn care, and this is the second part of two stages. The purpose of this second step is to enable learners to gain an understanding of what quality of care is from the perspective of users and why quality is important for the post-2015 agenda on maternal and newborn health in low- and middle- income countries. In the previous step we highlighted the two important perspectives to quality of care– the supply or provision side and the demand or experience side.
And we learnt previously that recognition of the importance of quality has been comparatively limited at policy and programme levels in many low- and middle-income countries until quite recently. And I emphasise that this is partly owing to the focus on the indicators of uptake of care but also to the complexities of measuring multiple dimensions of quality. Nevertheless, recognition of the supply side of care has progressed in the last few years, linked to interventions to improve quality– many of which also act as information gathering tools, such as audits and adverse event reviews.
These tools, which help to measure the supply side of care, not only tell you about what the level of care is, but they also are giving important information that can improve the quality of care. By comparison, attention to the demand side, to the experience of care as reported by women themselves, is still in its infancy in terms of robust evidence and methods applied across several low- and middle-income countries. Of course, however, assessing women’s satisfaction with delivery care– both in terms of the physical environment, for example a small maternity unit seen in this picture, as well as the treatment women receive from health workers– women’s satisfaction itself is not a new topic in some parts of the world.
And in fact, there’s been a huge amount of research over the last 50 or 60 years in high-income countries that really look at many dimensions of satisfaction. However, in recent years, there have been more systematic attempts to capture sensitive issues around core treatment of women in labour and delivery in low- and middle- income countries and to show the magnitude and consequences of those experience of poor quality care. Robust qualitative studies have demonstrated in low- and middle-income countries, both the importance of gaining women’s trust for them to be able to report openly about poor care– especially when alternative sources of care are limited.
For example, if there’s only one provider in the village and they’re asked to speak openly about the standard of care they received, that’s quite compromising for them. But these studies also show the impact of poor care on the subsequent uptake by women as well as the long-term psychosocial consequences of having poor care– or what has now come to be known as disrespectful and abusive care. In part, the exploration of these sensitive issues have been stimulated by wider recognition of women’s sexual and reproductive rights and of rights-based approaches to improving health and to reducing maternal mortality.
Well-respected advocacy groups, such as the White Ribbon Alliance, have taken up some of these issues and developed powerful materials to raise awareness of poor quality of care, as manifested in disrespectful and abusive treatment in labour. Over the last three to four years, the White Ribbon Alliance has been championing the universal rights of childbearing women as seen in this slide, which flags seven categories of disrespect and abuse and relates these to the violation of seven fundamental human rights, such as liberty. A powerful advocacy video on this can be viewed at the URL which is cited on this slide.
Complementary work by the Population Council in East Africa has also highlighted profound inequities around disrespect and abuse of poor experience of care which is borne disproportionately in most societies by the most marginalised and disadvantaged groups of women. The harsh reality of the poorest care being received by the poorest women has been revealed in several studies across low- and middle-income countries. But as I was noting earlier, quality of care has got many dimensions, and poor care from health workers is but one element and certainly not the universal practice among providers. Indeed, many other studies show that most health workers have the same desire to provide good quality care as women that want to receive good quality care.
So it’s a shared agenda. The goal of good quality care is something that is shared by women and by providers. This means, if we move to slide six, that the inadequacies in the care environment, some of those inadequacies that are highlighted in the previous step in this course– such as lack of water and sanitation– are neither acceptable to women and their families, nor to care providers. So the care providers that you’re seeing in this facility in part of West Africa, they want to provide good, respectful, good hygiene, good infrastructure. That’s their common desire. It’s the same as what women desire. It’s not the providers.
Most providers do not want to practise in a poor environment nor do they want their treatment to be disrespectful and abusive. The same would apply even in a small birthing unit, such as that seen here in Bangladesh. So the importance of recognising quality as a shared agenda is increasingly being seen as a core foundation for health programmes and interventions in the period beyond 2015. In other words, high and equitable coverage is crucial along the entire continuum of care for mothers and newborns, but in the absence of equal attention to quality, the real health gains will continue to be limited. This matters acutely for some points on the continuum of care, such as the moment of childbirth.
As the upward trends in institutional delivery continue beyond 2015– seen here for four countries– the importance of ensuring a good quality on the supply and demand side of care will also grow in importance. In other words, for maternal and newborn survival and health to benefit from increasing uptake, the care that is received in institutions needs to be clinically effective, safe, and a good experience– which tallies well with the earlier definition I gave in the previous step. And quality has broader implications for health in the post-2015 agenda, which is being driven now by 17 Sustainable Development Goals.
Only one of the 17 Sustainable Development Goals targets health, but universal health coverage is being positioned as central to this and to the other SDGs. And although the word “coverage” is what’s being used in universal health coverage, if you look at the detailed elaboration behind this in the technical documents related to the sustainable development goals, you’ll see that actually what is meant is effective coverage– effective universal coverage. The term “effective coverage” actually means high and equitable coverage of good quality care. So quality is in there. Quality is about ensuring health services that are available, accessible, acceptable, affordable, and of high quality. And here, we see the priorities articulated more specifically around maternal and newborn health and survival.
These are priorities that have been articulated recently in a key document talking about the period beyond 2015. And if you look at this list, you can see one of the headlines is “advancing quality, respectful care.” How to improve quality– so not that it’s just important but how to actually go about improving quality– is very much a pressing question for implementation research throughout the world. The evidence base on interventions that actually improve quality is still growing in low- and middle-income countries. But a recent systematic review summarised the effects of different approaches which have been trialled in other countries.
If you look at the next slide, it shows you a whole series of interventions which have actually been trialled in the context of randomised trials. And it shows you in these contexts and in context of trials that some of the effects are quite small and modest. But even though the effects of these single interventions are small and modest, not improving quality of care is also not an option. Improving quality of care is a core element of strengthening health systems. And even with interventions producing small effects, they still need to be championed as part of health system strengthening.
So if we look at findings from the broader science of quality improvement, what it shows– that the requirements for quality improvement actually are composite. In other words, we shouldn’t be talking about single interventions. We should see quality improvement as a package. And here in this slide, it shows you some of the essential ingredients– adequate resources; active engagement, not passive engagement, of health professionals in quality improvement; the issue of sustained managerial focus. The fact that there needs to be different aspects of the interventions. Action needs to be coordinated throughout the health system, and there needs to be major investment in training– as well as the availability of robust and timely monitoring of quality.
Now, most of these ingredients are actually very central and integral to broader health system strengthening, and they also help to demonstrate the strong behavioural element of quality of care. And crucially, as you’ll see from the red arrow right at the bottom of the slide, important issue of context-specific implementation. Particularly, quality has a strong behavioural element, and behavioural factors often vary very importantly between context. In other words, to have effective change and improvement in quality, we need to make sure that what is being proposed is very fit for purpose in that particular context– both in the supply side as well as the demand side.
The expectation and demands of women in one context, will not be the same as in another context. And how we ensure women’s demands are met will also need to vary. In other words, context-specific implementation applies across most of the whole of maternal and newborn health continuum. So finally, just to summarise what we’ve learned in this step. Firstly, again to reemphasize that high and equitable coverage of maternal and newborn care is necessary, but it’s not sufficient alone. Quality is absolutely crucial. Both the supply side of services as well as the demand or experience of care are the essential components of quality. There’s no point in addressing just the supply side and ignoring the experience of care as well.
Recent studies and advocacy have highlighted some experience of women which showed disrespect and abuse during labour and delivery care. The provision and receipt of good quality maternity care is, in fact, a goal commonly shared between women and health care providers. It’s certainly not the case that most providers wish to provide disrespectful or abusive care. In other words, there is a shared agenda. When we start talking about beyond 2015 and the achievement of the Sustainable Development Goals, there is a prioritisation of universal health coverage, and that includes an essential element to do with quality. But at the end of the day, effective interventions for continuously improving the quality of care for mothers and newborns ultimately requires context-specific implementation.

What about the experience, or demand side of care, including respect, dignity, equity and emotional support? Methods relating to the measurement of satisfaction with care are still in their infancy, and while it is clearly essential, we lack robust evidence about how poor experiences can affect uptake of services in low- and middle-income countries.

Over the course of these two steps we’ve seen that the best quality of care is achieved when the experiences and requirements of both health care providers and users are closely aligned. If we know what users of health care facilities want in order to be satisfied, what would you expect to be supplied by a facility offering high quality delivery 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.

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Improving the Health of Women, Children and Adolescents: from Evidence to Action

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