Graham, Wendy J

McCaw-Binns, Affette

Munjanja, Stephen

PLoS Medicine

English

PubMed

Wendy J. Graham

Affette McCaw-Binns

Stephen Munjanja

Crossref

Translating Coverage Gains into Health Gains for All Women and Children: The Quality Care Opportunity

Aberdeen University Research

PerspectiveTranslating Coverage Gains into Health Gains for All Womenand Children: The Quality Care OpportunityWendy J. Graham1*, Affette McCaw-Binns2, Stephen Munjanja31 Immpact, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom, 2Department of Community Health and Psychiatry, University of WestIndies-Mona, Kingston, Jamaica, 3Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, ZimbabweThe proportion of women and childrenreceiving health care in the poorest coun-tries is increasing [1]. Unfortunately, mark-ers of improved health outcomes, such asfalling maternal or newborn mortality, havenot matched expectations from the gains inthe coverage of care. Robust evidence existsfor one explanatory factor: the poor–richgaps in coverage found along the continu-um of care for women and children, andparticularly for the crucial period aroundchildbirth [2]. The more-neglected expla-nation for the mismatch between coverageand health outcomes is the quality of thecare provided to women and children,which is the focus of Year 1 of the MaternalHealth Task Force (MHTF)-PLOS Collec-tion on Maternal Health (http://www.ploscollections.org/maternalhealth_year1)and our short commentary.Although inadequacies in care havelong been noted across the world and formany health problems [3], a focus on themagnitude, costs, and consequences spe-cifically for women and children in low-income countries is relatively new, and stillhas not achieved the status of a politicalpriority [4]. This contrasts markedly withthe attention paid to the coverage of care.Here we seek to highlight the synergiesbetween inequalities in coverage andquality. The inverse care law [5] proposesthat quality of care varies inversely withneed, and we extend this to emphasizethat poor quality care is disproportionatelyborne by the poorest groups of womenand children. Our commentary is struc-tured around a key cause and a conse-quence of the neglect of quality—weakmeasurement and poor evidence foraction—and concludes with priorities forseizing the quality care opportunity.Measurement TrapsIn global health there are numerousexamples of measurement constraints dis-torting priorities for policies, programmes,and research [6]. In maternal health,this situation has been described as ameasurement trap [7] that reflects both weakroutine information systems and a lack ofconsensus on critical concepts, definitions,and tools. The diversity of interpretationsof what constitutes quality and thus qualitycare can be seen across the 18 articles inthis MHTF-PLOS Collection. In ourcommentary we adopt the well-accepteddefinition: ‘‘quality means clinical effec-tiveness, safety, and a good experience forthe patient’’ [8] and give three examples ofhow measurement traps impact on theevidence and understanding of quality.The weak routine patient record sys-tems in many low-income countries presentserious challenges to quality assessment andimprovement, using tools such as criterion-based audit, to medical liability, andcrucially, to clinical case management.Selection biases in the cases reviewed arisefrom incomplete and inaccurate registers,and conclusions on standards of clinicalcare may be distorted by missing or poorlycompleted patient records [9]. The under-reporting of adverse outcomes, such asmaternal deaths [10], can undermine localrecognition of poor quality care and theneed for corrective action. Measurementand data constraints have, in turn, led to afailure to recognise levels of quality along acontinuum, and to neglect of essentialrequirements for delivering quality care,like basic infrastructure for providing waterand sanitation in facilities [11,12].A second measurement trap relates tothe data source for most coverage indica-tors—cross-sectional population surveys.The Demographic and Health Surveys(DHS) have made an enormous contribu-tion in low-income countries, providing apicture of coverage based on women’s ownreports of health care services or interven-tions that they or their children neededand received. However, not all sub-groupsor types of experiences of care arerepresented. One such group is womenexperiencing stillbirths, since the majorityof the questions in the DHS relate towomen with live births. These surveys areused to judge country progress in coverage[1], and thus population biases are rele-vant. Studies have found that women withlive births are more likely than those withCitation: Graham WJ, McCaw-Binns A, Munjanja S (2013) Translating Coverage Gains into Health Gains for AllWomen and Children: The Quality Care Opportunity. PLoS Med 10(1): e1001368. doi:10.1371/journal.pmed.1001368Published January 15, 2013Copyright:  2013 Graham et al. This is an open-access article distributed under the terms of the CreativeCommons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,provided the original author and source are credited.Funding: No specific funding was received for writing this article.Competing Interests: The authors have declared that no competing interests exist.Abbreviations: DHS, Demographic and Health Surveys; MHTF, Maternal Health Task Force.* E-mail: w.graham@abdn.ac.ukProvenance: Commissioned; externally peer reviewed.Linked CollectionThis Perspective was commissionedto reflect on the quality of maternalhealth care, the theme of Year 1 ofthe Maternal Health Task Force-PLOS Collection on maternal health.The Year 1 Collection contains 18new, outstanding research andcommentary articles from a widerange of settings and authors indeveloped and developing coun-tries, providing needed evidence toimprove the quality of maternalhealth care worldwide.More information and the full list ofarticles can be found at the Collectionpage: http://www.ploscollections.org/maternalhealthPLOS Medicine | www.plosmedicine.org 1 January 2013 | Volume 10 | Issue 1 | e1001368stillbirths to tolerate poor quality care [13]and to feel less need for skilled care insubsequent pregnancies [14]. The well-established link between adverse birthevents and inadequate care, and theclustering of both poor outcomes and poorcare among the poorest women, empha-sizes the urgent need for co-measurementof coverage and quality.The third example comes from thedominance of supply-side approaches toroutinely measuring quality in low-incomesettings. Functioning health systems thathave successfully embedded a culture ofquality respond to the demand-side bycontinuously capturing the views andvoices of users, both in private and inpublic service provision [15]. This Collec-tion and other articles offer valuableinsights from research studies on women’sexpressed needs, such as trust and respectduring childbirth, and there are noveltechniques, like photo-narratives [16], forcapturing these views. However, studiestypically have special skills and resources attheir disposal, and thus tools developedthrough research [17] may not be feasiblefor routine quality assessment, improvement,and assurance in low-income countries.Evidence GapsQuality care can be viewed as either adesired goal, and so used to judge thehealth system, or as an intervention forachieving health outcomes, such as im-proved survival. In both cases, the majorevidence gap is how to implement care thatis clinically effective, safe, and a goodexperience for the patient. Quality care isthus part of the wider challenge of imple-mentation in global health, characterisedby a weak evidence base and underdevel-oped science [18]. Not only are theretechnical issues to delivering quality care,but also social and cultural factors, makingthe implementation context crucial [19].Relevant evidence and lessons will thusemerge not solely from research, and waysto capture and synthesise programmaticexperience are also needed.To identify priority evidence gaps in theimplementation of quality care for womenand children, we recommend a consensus-building exercise at country or regionallevels [20]. Here we express our own viewson just three key gaps. Firstly, there is anotable lack of evidence on financial issuesin relation to quality. This includes robustcosting of quality improvement and assur-ance interventions, as well as the impact offinancing mechanisms, such as pay forperformance, on quality in both publicand private contexts. Improving quality iswidely viewed as a net cost, and moreevidence is needed on financial savings inaddition to lives saved [21]. The secondevidence gap relates to the strong behav-ioural component of quality improvementamong providers and women users, andthe need for deeper insights to help explainattitudes and practises, such as motivationand conscientiousness. Inputs should besought from a wider range of disciplines,including psychology and organisationalscience, as well as from other sectors, likecommerce, for the management of perfor-mance and risks. Finally, we highlight theevidence gaps on patient safety strategiesand interventions. The basic principle of‘‘first do no harm’’ has particular reso-nance in maternity care [22]. The mount-ing evidence of high levels of harm inhealth care institutions in low-incomecountries suggests the need for a systemsapproach to human error, such as JamesReason’s [23] ‘‘Swiss cheese model,’’which shows how the alignment of failingsin health system safeguards brings hazardsinto contact with victims. There areexamples of such alignment and of novelresponses in this Collection, includingSpector and colleagues’ [24] checklistapproach to ensuring patient safety.Seizing the Quality CareOpportunityImproving and assuring the quality ofcare received by all women and childrenin low-income countries is crucial toachieving health, equity, and human rightsgoals. Now is the time to seize thisopportunity and to reposition quality atthe centre of debates on universal healthcoverage and in post-2015 developmentpriorities. ‘‘Effective coverage’’ should bethe new narrative in these debates, mean-ing high and equitable coverage of qualitycare. This repositioning requires a funda-mental shift in policy and programmemindsets to accept quality care as essentialto protecting lives, well-being, and scarcehealth resources. We conclude by high-lighting four priorities to help create apolicy, programme, and research environ-ment conducive to quality health systems.1. Listen to women users1. Quality health systems are those thatrespond to the people they serve. Thechallenges of capturing the valid viewsand opinions of women users of publicand private services in low-incomecountries are non-trivial, particularlyoutside of a research context. Tacklingthese will require commitment frompolicy-makers, managers, and practi-tioners, and should be linked to thedevelopment of accountability frame-works. Although these frameworks haveoften focused on community voicesaround adverse events like maternaldeaths, this needs to broaden to includethe perspectives of women survivorswith good and bad care experiences.2. Create a learning movement2. Assuring quality care for women andchildren in low-income settings isfundamentally about implementation.A learning movement is needed toenable efficient exchange of implemen-tation lessons, and to organise these interms of contexts. Some, but not all,lessons will be research-based, anddisseminating these will require fundersand journals to temper their biasestowards only reporting success, since itis equally important to know whatdoesn’t work. Such an honest and openlearning movement needs to be multi-disciplinary, multi-professional, andmulti-sectoral, with a willingness tothink and work outside the box, tocapture innovative thinking from theglobal south and north and frombusiness and industry, and to be ac-tion-focused. The next generation ofservice providers must also be nurturedby the movement and supported by asystem that enables woman-centredcare, best practices, and continuingprofessional development. The learningand implementation experiences of allcare providers must be voiced to policydecision-makers and to civil society.3. Get back to basics3. Focusing on the human dimension toquality health systems has been under-standable, but the basic physical envi-ronment in which providers practiceand women and children receive careneeds comparable attention. The poorstate of water and sanitation provisionin maternity units, for instance, isalarming and, along with poor hygienepractices, presents a real risk of harmand a return to epidemics of infection,complicated by the 21st century prob-lem of antibiotic resistance. There is aneed to routinely audit adequacy ofbasic infrastructure and equipment, tolink this performance to accountabilityframeworks, and to ensure relevantindicators are included in post-2015monitoring platforms.4. Invest in patient records andregisters4. The very foundations of quality assess-ment and assurance processes—patientrecords and registers—remain inade-quate in many low-income countries,PLOS Medicine | www.plosmedicine.org 2 January 2013 | Volume 10 | Issue 1 | e1001368and often have not benefited in broaderefforts to strengthen health informationsystems. The situation must changewhereby women and children enteringthe health care system remain invisiblesince patient records are not issued norentries made in registers. Such recordsand registers should be seen as funda-mental to case management and clinicaltraining, and to detecting importantchanges in health burdens so the servicecan respond. Innovations are needed incapture, collation, and storage, such assimple electronic registers and woman-held case notes, and in disaggregatingdata to enable routine assessment of thequality of care received by the mostdisadvantaged women and children.These improvements must extendthrough to the use of data for action,from the clinical setting to policy levels,and these need strong political andfinancial investment. The state of pa-tient records and registers is ultimately amirror of quality health systems andthus also a valid development target.We have focused on quality carespecifically for women and children.But seizing the quality care opportunitywill also benefit the wider health system,care providers, and other populationgroups.AcknowledgmentsThanks to Julia Hussein and Sophie Witter forcomments on earlier versions of this essay.Author ContributionsWrote the first draft of the manuscript: WJG.Contributed to the writing of the manuscript:WJG AMB SM. 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Translating coverage gains into health gains for all women and children : the quality care opportunity

Wendy J Graham

Directory of Open Access Journals

Translating coverage gains into health gains for all women and children: the quality care opportunity.

A social explanation for the rise and fall of global health issues.

Closing the gaps: from science to action in maternal, newborn, and child health in Africa.

Completeness and quality of maternal mortality measurement from vital registration data in Jamaica.

Countdown to 2015: building a future for women and children: the 2012 report.

Criterion-based clinical audit to assess quality of obstetrical care in low- and middle-income countries: a systematic review.

Crossing the quality chasm: a new health system for the 21st century. Available: http://www.nap.edu/html/quality_ chasm/reportbrief.pdf.

Effective, safe and a good patient experience.

Evaluating quality of obstetric care in low-resource settings: building on the literature to design tailor-made evaluation instruments - an illustration in Burkina Faso.

Evidence-based priority setting for health care and research: tools to support policy in maternal, neonatal, and child health in Africa.

Getting it right: improving maternal health through water, sanitation & hygiene. Haarlem, The Netherlands: Simavi. Available: http:// washresources.wordpress.com/2012/10/19/ getting-it-right-improving-maternal-healththrough-water-sanitation-hygiene/.

Global initiatives for improving hospital care for children: state of the art and future prospects.

How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys.

Human error: models and management.

Improving implementation: building research capacity in maternal, neonatal, and child health in Africa.

Improving maternal health: getting what works to happen.

Improving quality of care for maternal and newborn health: prospective pilot study of the WHO Safe Childbirth Checklist program.

Improving value in health care: measuring quality. Health Ministerial Forum on Quality of Care,

Listening to women’s voices: the quality of care of women experiencing severe maternal morbidity,

Maternal health and the measurement trap.

New signal functions to measure the ability of health facilities to provide routine and emergency newborn care. PLoS Med 9(11):

Perceptions of quality of reproductive care services in Bolivia: use of photo prompts and surveys as an impetus for change.

The inverse care law.

The social dimensions of safety incident reporting in maternity care: the influence of working relationships and group processes.

Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data.

https://aura.abdn.ac.uk/bitstream/2164/3660/1/Translating_coverage.pdf

Translating coverage gains into health gains for all women and children : the quality care opportunity

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