Despite global commitment to universal health coverage with quality, poor quality of care (QOC) continues to impact health outcomes for mothers and newborns, especially in low-and-middle income ...countries. Although there is much experience from small-scale projects, without a long-term perspective it is unclear how to implement quality of care effectively and consistently for impact. In 2017, ten countries together with the WHO and a coalition of partners established the Network for Improving Quality of Care for Maternal, Newborn and Child Health (the Network). The Network agreed to pursue four strategic objectives-Leadership, Action, Learning and Accountability (LALA) for QOC. This paper describes, analyses and reflects on what has worked and some of the challenges faced in implementation of the LALA framework. The implementation of the LALA framework has served as a catalyst to develop an enabling environment for QOC in the Network countries through strengthening the policy, implementation, accountability and community engagement for quality care. Developing an enabling health system environment takes time, but it is possible and shows results. The implementation shows that health systems continue to face persistent challenges such as capacities to quickly scale up changes across subnational levels, limited workforce capability to implement quality improvement consistently and gaps in quality of relevant data. The implementation has also highlighted the need to develop new mechanisms for community engagement and learning systems that inform scaling up of good QOC practices across programmes and levels of care. Moving forward, the Network countries will build on the experiences and lessons learned and continue to strengthen the implementation of LALA strategic objectives for impact. We hope the Network experience will encourage other countries and partners to adopt the Network implementation model to enable delivery of quality care for everyone, everywhere, and actively collaborate and contribute to the QOC global learning network.
The CRADLE (Community blood pressure monitoring in Rural Africa: Detection of underLying pre-Eclampsia) Vital Signs Alert device-designed specifically to improve maternity care in low resource ...settings-had varying impact when trialled in different countries. To better understand the contextual factors that may contribute to this variation, this study retrospectively evaluated the adoption of CRADLE, during scale-up in Sierra Leone.
This was a mixed methods study. A quantitative indicator of adoption (the proportion of facilities trained per district) was calculated from existing training records, then focus groups were held with 'CRADLE Champions' in each district (n = 32), to explore adoption qualitatively. Template Analysis was used to deductively interpret qualitative data, guided by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) Framework.
Substantial but non-significant variation was found in the proportion of facilities trained in each district (range 59-90%) X
(7, N = 8) = 10.419, p = 0.166. Qualitative data identified complexity in two NASSS domains that may have contributed to this variation: 'the technology' (for example, charging issues, difficulty interpreting device output and concerns about ongoing procurement) and 'the organisation' (for example, logistical barriers to implementing training, infighting and high staff turnover). Key strategies mentioned to mitigate against these issues included: transparent communication at all levels; encouraging localised adaptations during implementation (including the involvement of community leaders); and selecting Champions with strong soft skills (particularly conflict resolution and problem solving).
Complexity related to the technology and the organisational context were found to influence the adoption of CRADLE in Sierra Leone, with substantial inter-district variation. These findings emphasise the importance of gaining an in-depth understanding of the specific system and context in which a new healthcare technology is being implemented. This study has implications for the ongoing scale-up of CRADLE, and for those implementing or evaluating other health technologies in similar contexts.
Availability of skilled care at birth remains a major problem in most developing countries. In an effort to increase access to skilled birth attendance, the Kenyan government implemented the ...community midwifery programme in 2005. The aim of this programme was to increase women's access to skilled care during pregnancy, childbirth and post-partum within their communities.
Qualitative research involving in-depth interviews with 20 community midwives and six key informants. The key informants were funder, managers, coordinators and supervisors of the programme. Interviews were conducted between June to July, 2011 in two districts in Western and Central provinces of Kenya.
Findings showed major challenges and opportunities in implementing the community midwifery programme. Challenges of the programme were: socio-economic issues, unavailability of logistics, problems of transportation for referrals and insecurity. Participants also identified the advantages of having midwives in the community which were provision of individualised care; living in the same community with clients which made community midwives easily accessible; and flexible payment options.
Although the community midwifery model is a culturally acceptable method to increase skilled birth attendance in Kenya, the use of skilled birth attendance however remains disproportionately lower among poor mothers. Despite several governmental efforts to increase access and coverage of delivery services to the poor, it is clear that the poor may still not access skilled care even with skilled birth attendants residing in the community due to several socio-economic barriers.
Introduction: Infection prevention and control (IPC) is crucial to limit health care-associated infections and antimicrobial resistance. An operational research study conducted in Sierra Leone in ...2021 reported sub-optimal IPC performance and provided actionable recommendations for improvement. Methods: This was a before-and-after study involving the national IPC unit and all twelve district-level secondary public hospitals. IPC performance in 2021 (before) and in 2023 (after) was assessed using standardized World Health Organization checklists. IPC performance was graded as: inadequate (0-25%), basic (25.1-50%), intermediate (50.1-75%), and advanced (75.1-100%). Results: The overall IPC performance in the national IPC unit moved from intermediate (58%) to advanced (78%), with improvements in all six core components. Four out of six components achieved advanced levels when compared to the 2021 levels. The median score for hospitals moved from basic (50%) to intermediate (59%), with improvements in six of eight components. Three of four gaps identified in 2021 at the national IPC unit and four of seven at hospitals had been addressed by 2023. Conclusions: The study highlights the role of operational research in informing actions that improved IPC performance. There is a need to embed operational research as part of the routine monitoring of IPC programs.
Olive Cocoman and colleagues argue that national leadership for quality of care requires working in a co-leadership model such that quality and programme units have equal standing and clearly defined ...individual roles and responsibilities
Introduction: Infection prevention and control (IPC) is crucial to limit health care-associated infections and antimicrobial resistance. An operational research study conducted in Sierra Leone in ...2021 reported sub-optimal IPC performance and provided actionable recommendations for improvement. Methods: This was a before-and-after study involving the national IPC unit and all twelve district-level secondary public hospitals. IPC performance in 2021 (before) and in 2023 (after) was assessed using standardized World Health Organization checklists. IPC performance was graded as: inadequate (0–25%), basic (25.1–50%), intermediate (50.1–75%), and advanced (75.1–100%). Results: The overall IPC performance in the national IPC unit moved from intermediate (58%) to advanced (78%), with improvements in all six core components. Four out of six components achieved advanced levels when compared to the 2021 levels. The median score for hospitals moved from basic (50%) to intermediate (59%), with improvements in six of eight components. Three of four gaps identified in 2021 at the national IPC unit and four of seven at hospitals had been addressed by 2023. Conclusions: The study highlights the role of operational research in informing actions that improved IPC performance. There is a need to embed operational research as part of the routine monitoring of IPC programs.
The Child Health and Mortality Prevention Surveillance (CHAMPS) Network programme undertakes post-mortem minimally invasive tissue sampling (MITS), together with collection of ante-mortem clinical ...information, to investigate causes of childhood deaths across multiple countries. We aimed to evaluate the overall contribution of pneumonia in the causal pathway to death and the causative pathogens of fatal pneumonia in children aged 1–59 months enrolled in the CHAMPS Network.
In this observational study we analysed deaths occurring between Dec 16, 2016, and Dec 31, 2022, in the CHAMPS Network across six countries in sub-Saharan Africa (Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) and one in South Asia (Bangladesh). A standardised approach of MITS was undertaken on decedents within 24–72 h of death. Diagnostic tests included blood culture, multi-organism targeted nucleic acid amplifications tests (NAATs) of blood and lung tissue, and histopathology examination of various organ tissue samples. An interdisciplinary expert panel at each site reviewed case data to attribute the cause of death and pathogenesis thereof on the basis of WHO-recommended reporting standards.
Pneumonia was attributed in the causal pathway of death in 455 (40·6%) of 1120 decedents, with a median age at death of 9 (IQR 4–19) months. Causative pathogens were identified in 377 (82·9%) of 455 pneumonia deaths, and multiple pathogens were implicated in 218 (57·8%) of 377 deaths. 306 (67·3%) of 455 deaths occurred in the community or within 72 h of hospital admission (presumed to be community-acquired pneumonia), with the leading bacterial pathogens being Streptococcus pneumoniae (108 35·3%), Klebsiella pneumoniae (78 25·5%), and non-typeable Haemophilus influenzae (37 12·1%). 149 (32·7%) deaths occurred 72 h or more after hospital admission (presumed to be hospital-acquired pneumonia), with the most common pathogens being K pneumoniae (64 43·0%), Acinetobacter baumannii (19 12·8%), S pneumoniae (15 10·1%), and Pseudomonas aeruginosa (15 10·1%). Overall, viruses were implicated in 145 (31·9%) of 455 pneumonia-related deaths, including 54 (11·9%) of 455 attributed to cytomegalovirus and 29 (6·4%) of 455 attributed to respiratory syncytial virus.
Pneumonia contributed to 40·6% of all childhood deaths in this analysis. The use of post-mortem MITS enabled biological ascertainment of the cause of death in the majority (82·9%) of childhood deaths attributed to pneumonia, with more than one pathogen being commonly implicated in the same case. The prominent role of K pneumoniae, non-typable H influenzae, and S pneumoniae highlight the need to review empirical management guidelines for management of very severe pneumonia in low-income and middle-income settings, and the need for research into new or improved vaccines against these pathogens.
Bill & Melinda Gates Foundation.
BackgroundMost childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe ...adherence to World Health Organization recommendations for the management of leading causes of death among children. MethodsWe conducted a retrospective, descriptive study examining clinical data for children aged 1-59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment, December 2016-June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration. FindingsCHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h. InterpretationProvision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence. FundingBill & Melinda Gates Foundation.
Background: Most childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe ...adherence to World Health Organization recommendations for the management of leading causes of death among children. Methods: We conducted a retrospective, descriptive study examining clinical data for children aged 1–59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment, December 2016–June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration. Findings: CHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h. Interpretation: Provision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence. Funding: Bill & Melinda Gates Foundation.
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