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Better health processes and outcomes in Low-Income
Countries: How do we get there?
A. Maina Boucar, MD, MPH
USAID – Applying Science to Strengthen and Improve Systems
Regional Office for Francophone Africa
Niamey – Niger
USAID Applying Science to Strengthen and Improve Systems2
In Niger…
• A woman dies every 2 hours of pregnancy/ childbirth
complications
• A woman faces a one in seven chance of dying from
pregnancy-related complications during her lifetime
• Maternal Mortality Ratio: 620/100,000 (DHS 2012)
• Post-partum hemorrhage is the single largest cause of
maternal mortality in Niger (29%)
• BP linked conditions are the 3rd cause of maternal
mortality
• 40 % of children suffer from chronic malnutrition
• 50% of early childhood deaths associated with malnutrition
WHY?
USAID Applying Science to Strengthen and Improve Systems3
Why do we fail to address these issues?
Evidence base high impact
interventions (examples)
PEE screening and case
management
Infection Prevention
AMSTL, ENC
Blood management
USAID Applying Science to Strengthen and Improve Systems4
Hausa Proverb
“The world is like
a pregnant
woman;
you never know
what will
emerge.”
USAID Applying Science to Strengthen and Improve Systems
Opportunities and challenges
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• Post-partum hemorrhage is the single largest cause of
maternal mortality in Niger
• Active management of third stage of labor (AMTSL) reduces PPH by over 50% when correctly implemented;
• The challenges for us were:
How to move research into practice--at scale--in the resource-poor settings where most women die of PPH?
How to strengthen health systems to implement high impact interventions at scale?
USAID Applying Science to Strengthen and Improve Systems6
USAID-Health Care Improvement Project Niger
USAID-HCI assisted MOH in 48 MOH sites in 7 of 8
regions
Maternal Newborn Care:
AMTSL/Essential Newborn Care:
• 33 MOH sites; 64% districts; 31,085 births in 2008
Pre-eclampsia/Eclampsia:
• 31 MOH sites; 119,045 patient contacts/year
Child Health:
IMCI and Malnutrition
• 15 MOH sites
FY08 Budget: $800,000; 4 staff
USAID Applying Science to Strengthen and Improve Systems
Participants to a Provincial Learning
Session
USAID Applying Science to Strengthen and Improve Systems
Program Impact: NigerReduction in Post-partum Hemorrhage
10
USAID Applying Science to Strengthen and Improve Systems11
Examples of Changes
AMTSL stamp
Cooler for Ocytocine
Infection
Prevention
Materials
Delivery privacy areas
AMSTL
Reorganization of call schedule to ensure skilled provider at majority of births
Reorganization of patient flow to include separate triage, labor, and delivery areas
Daily review/feedback on completed partograms by senior midwife
USAID Applying Science to Strengthen and Improve Systems
19%
95% 90%94%94%
0%
1%
2%
3%
4%
5%
0%
20%
40%
60%
80%
100%
J A J O J A J O J A J O J A J O J A J A
Pe
rc
en
tag
e o
f P
os
t P
artu
m H
em
orrh
ag
es
de
tec
ted
Pe
rc
en
tag
e
Observation: % adherence to AMTSL norms
Simulation: % adherence to AMTSL norms
Record review: % adherence to AMTSL norms
Record review: % deliveries with 3 key AMTSL components
Record review: % facility deliveries with Post Partum Hemorrhage
2006 20082007
Start of collaborative End of collaborative
2009 2010
Sustaining gains for active management of the third stage of labor (AMTSL) in 20 sites in Niger
USAID Applying Science to Strengthen and Improve Systems
Scaling up EONC best practices fromNiger to Mali
15
Niger
Mali
USAID Applying Science to Strengthen and Improve Systems16
Wave 1 (Oct 2009) ~ 1066 births per month in 41 facilities (2 districts) Wave 2 (Oct 2011) ~267 births per month in 21
facilities Wave 3 (Oct 2012) ~1100 births per month in 83 facilities (3 new districts)
Mali: Preventing post-partum hemorrhage in Kayes Region
0
10
20
30
40
50
60
70
80
90
100
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Pe
rce
nta
ge
of
bir
ths
re
ce
ivin
g A
MT
SL
Po
st-
pa
rtu
m h
em
orr
ha
ge
ra
te
Percentage compliance with AMTSL norms and post partum hemorrhage rate. Comparison of wave 1, 2 and 3 sites in 145 health
facilities in 5 districts of MaliWave 1 sites PPH Wave 3 sites PPH Wave 1 sites AMTSL
Wave 3 sites AMTSL Wave 2 sites AMTSL Wave 2 sites PPH
USAID Applying Science to Strengthen and Improve Systems
Jan 10: Baseline results restitution and orientation in
QI and collaborative
May 10: Coaching visits
Nov 10: LS2 (per district) + key changes sharing
Apr 11: LS3
Jun 11: Coaching visits
Nov 09: Baseline Assessment
Feb-Mar 10: Providers’ training in AMTSL/ENC
and QINiger EONC Collaborative
Experience sharing
Apr 10: Training of coaches; LS1 + Key successful
changes sharing on Niger
Jul 10: Coaching Visits
Feb 11: Coaching visits
Mar 11: Coaches’ meeting
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
0.0
1.0
2.0
3.0
4.0
5.0
9-Oct
N D J10 F M A M J J A S O N D J11 F M A M J J A S O N D
% B
irth
s c
ov
ere
d b
y A
MT
SL
po
st p
art
um
he
mo
rrh
ag
e r
ate
% post partum hemorrhage % births covered by AMTSL
Average # monthly births: 1,024
AMTSL coverage and post-partum hemorrhage rates in 41 target facilities,
Kayes & Diema Districts, Mali, Oct. 2009 – Dec. 2011
Mali: AMTSL & post-partum hemorrhage management
17
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The Science of Improvement
A structured approach to deliver
evidence based high impact
interventions at scale
USAID Applying Science to Strengthen and Improve Systems
Different Ways by Which Quality Can Become Better
• Through accumulation of knowledge and
experience over time
• Through trial and error
• Through advances in science and scientific
experiments
• By coincidence
• On the basis of improvement science
USAID Applying Science to Strengthen and Improve Systems
The Framework for Health Care Quality Improvement
USAID Applying Science to Strengthen and Improve Systems
Principles of Improvement
• “Fundamental Concept of Improvement:
“Every System is perfectly designed to achieve exactly the results it achieves”
• Principles of Improvement:
– Understanding work in terms of processes and systems
– Implementing high impact interventions by redesigning processes
– Process redesign by teams of front-line health care providers supported by
District and Regional Health Management Teams
– Focusing on patient needs and preferences in the redesign of processes
– Testing changes to see if they yield improvement
– Data management by teams of health care providers for continuous
improvement
– Shared Learning facilitated process by which multiple teams learning from
each other
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