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Boston University School of Public Health
Endline Study for Queen ‘Mamohato Memorial Hospital Public Private
Partnership
World BankMarch 11, 2014
Taryn Vian, PhDNathalie McIntosh, PhDAria Grabowski, MPH
Brian Jack, MDElizabeth Limakatso Nkabane–Nkholongo, RN/RM, BSN
Bram Brooks, MPH, DrPH(c)
Boston University Slideshow Title Goes Here
Boston University School of Public Health
Agenda Background Objectives and methods of study Findings (quantitative and qualitative) Discussion and recommendations
05/03/2023 2Lesotho Endline PPP Evaluation
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Boston University School of Public Health
Background
05/03/2023 3Lesotho Endline PPP Evaluation
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Goals: to extend / upgrade publicly funded health care services in the greater Maseru District and referral services for the country, and to engage the private sector in new ways for better outcomes in partnership with government.
Lesotho Endline PPP Evaluation 05/03/2023 4
Coelho & O’Farrell 2009; UCSF & PwC 2012
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Baseline Study in 2009 IFC engaged Lesotho Boston Health Alliance
(LeBoHA) to collect baseline on access, use, quality, referrals, costs and health outcomes Data from 2006-2007
Purpose: to support monitoring and evaluation, help design of output-based aid (OBA) indicators, serve as comparison to endline.
74 indicators of Queen Elizabeth II (QEII) hospital and 3 filter clinics. Service data analysis, chart reviews, casualty flow, referral
study, step down cost analysis, patient & provider satisfaction, systems descriptions
Lesotho Endline PPP Evaluation 05/03/2023 5
05/03/2023 6
QEII at baseline
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Photos: Mountains of Hope (video)
Overflow beds
Ward
Male surgical bath
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Presentation Title 05/03/2023 8
Maternity labor room
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Lesotho Endline PPP Evaluation
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Kitchen
Lesotho Endline PPP Evaluation
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Laundry
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Lesotho Endline PPP Evaluation
Incinerator
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Objectives and Methods
05/03/2023 13Lesotho Endline PPP Evaluation
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Endline Study Objectives
1. Describe endline situation of Queen ‘Mamohato Memorial Hospital Integrated Network (QMMH-IN) using quantitative indicators and narrative description;
2. Compare endline to baseline;3. Explore explanations for
changes and make recommendations.
Lesotho PPP Endline Study 05/03/2023 14
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Endline Methods Collected administrative and clinical data from hospital
systems and reports, observed clinical activities (triage) Conducted 41 key informant interviews Time period: Endline data were collected Feb-April 2013.
Endline data were Jan. 1 – Dec. 31, 2012, compared to Baseline data from April 1, 2006 – March 31, 2007
Analysis: 24 quantitative and 14 qualitative indicators Descriptions of management systems: HR, facilities &
equipment, drug supply, patient registration, referrals Thematic analysis of performance drivers and changes
Lesotho Endline PPP Evaluation 05/03/2023 15
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Findings
05/03/2023 16Lesotho Endline PPP Evaluation
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QMMH-Integrated Network (IN): 3 refurbished urban filter clinics (open 5/2010) and new 425-bed hospital and Gateway clinic (open 10/2011)
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Quantitative IndicatorsLesotho Endline PPP Evaluation 05/03/2023 18
StatisticQMMH-IN
2012QEII-IN
2007 % Diff
Total beds
414
417 -1%
Hospital beds
390
409 -5%
Filter clinic beds
24
8 200%
Inpatient admissions (hospital)
23,341
15,465 51%
Inpatient Days (hospital)
116,648
91,808 27%
Outpatient Visits (incl. filter clinics)
374,669
165,584 126%
Deliveries (incl. filter clinics)
7,431 5,116 45%
Average length of stay (hospital) 5.00 5.94 -16%Hospital occupancy 82% 61% 33%
390+35 private beds not yet open=425 (original plan)
of which,
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Mabote Qoaling Likotsi Gateway Hospital Outpatient (excluding casualty)
Hospital Casualty
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000 80,186
77,885
69,646
45,733
80,656
20,563 19,870
33,117
21,526
64,578
26,493
Hospital and Filter Clinic Ambulatory Visits
QMMH (2012) QE II (2007)
Am
bula
tory
Pat
ient
s
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Quantitative Indicators
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StatisticQMMH-IN
2012QEII-IN
2007 % Diff
Death Rate (incl. filter clinics) 7.1% 12.0% -41%
Maternity death rate (incl filter clinics) 0.21% 0.24% -10%
Pediatric pneumonia death rate (hospital) 11.9% 34.4% -65%
Still birth rate (incl. filter clinics) 1.9% 4.0% -53%Survival of very low birth weight infants, <=1,500 gr (hospital) 69.8% NA NA
C-section rate (incl. filter clinics) 26.8% 7.2% 272%
Patient satisfaction rate (incl. filter clinics) 86% 70.7% 22%
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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0%
5%
10%
15%
20%
25%
30%
35%
26%
25% 24%
31%32% 30%
33%
27% 27%25%
23% 20%
Monthly C-section Rate incl. filter clinics
Month
Perc
ent o
f C-S
ectio
n
Annual average: 26.8%
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Lesotho Endline PPP Evaluation 05/03/2023 22
0%
10%
20%
30%
40%
12%
24%34% 44%
Pediatric Pneumonia Deaths
QMMHQEII
Perc
ent o
f Dea
ths
NICU patients <= 1,500 grams (n = 43, 46%)
NICU patients > 1,500 grams (n=51, 54%)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
70%
82%
30%
18%
QMMH Neonatal Survival Rates
% Survived % Mortality
Perc
ent o
f Neo
nate
s in
NIC
U
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Lesotho Endline PPP Evaluation 05/03/2023 23
QMMH (n=75) QE II (n=303)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% 84%
0%
Patients Triaged in Casualty
Perc
enta
ge C
asua
lty P
atie
nts
Tria
ged
by
Nur
sing
Sta
ff in
Und
er 5
min
.
QMMH (n=400) QE II (n=54)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%93%
0%
Infection Control Compliance
Perc
ent o
f Han
d w
ashi
ng S
tatio
ns w
ith c
lean
sing
so
lutio
n an
d w
ater
with
in 1
0m o
f pat
ient
bed
Lesotho PPP Endline Evaluation 05/03/2023 24
QMMH QE II0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
100%
70%
Compliance with Maternal PMTCT protocol
% o
f Del
iver
ies
Compli
ant V
itamin
K
Compli
ant O
phtha
lmia
Neona
torum
Prev
entio
n
Ove
rall N
ewbo
rn Com
plian
ce0%
30%
60%
90%
100% 100% 100%49% 58% 54%
Newborn Protocol Compliance
QMMH QE II
% N
ewbo
rns
QMMH (n=134) QE II (n=378)0%
20%
40%
60%
80%
100%
100%
3%
Complete and Accessible Medical Records
% M
edic
al R
ecor
ds
QMMH IM (n=77)
QMMH BU (n= 319)
QE II (n=139)0%
10%20%30%40%50%60%70%80%90%
100%
100% 89%
73%
Medical Record Accessibility
% M
edic
al R
ecor
ds A
vaila
ble
Afte
r D
isch
arge
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Lesotho PPP Endline Evaluation 05/03/2023 25
QMMH (n=61,517)
Likotsi (n=11,169)
Mabote (n= 15,187)
Qoaling (n=8126)
QE II (n=391)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
86.1%91.8%
77.2%
69.0% 70.7%
Patient Satisfaction Survey ResultsPe
rcen
tage
of O
vera
ll Po
sitiv
e
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Main Entrance and Gateway Clinic
Lesotho Endline PPP Evaluation 2605/03/2023
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Security Monitors
27Lesotho Endline PPP Evaluation 05/03/2023
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Improved FacilitiesLesotho Endline PPP Evaluation 2805/03/2023
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New EquipmentLesotho Endline PPP Evaluation 2905/03/2023
When you are just out of school, you want to work and practice what you’ve been taught. But at QEII, you had nothing to use.
Now that we have the equipment, we can do the procedures. People are very happy that they can stay in the country for treatment.
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Improvements in SOPs, upkeepLesotho Endline PPP Evaluation 3005/03/2023
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Improvements in upkeep, SOPs The cleaning company is outsourced now, and maybe
that’s why it’s best. Before, an old woman would put her new mop in the bucket once and would do the whole floor without changing it. If you talked to her, she would say ‘You do your job, I’m doing mine.
There are standard operating procedures (SOPs), like a recipe. For example, this is how you admit a patient, these are the steps. It gives you an ease, because you know what you are supposed to do.
Here we are made to be part of the [hospital] policies and we are asked to adapt them to be relevant to our situation. We disseminate them to all teams, so they know how they should conduct themselves.
Lesotho PPP Endline Study 05/03/2023 31
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Use of work orders for non-scheduled repairs or equipment problems
32Lesotho Endline PPP Evaluation 05/03/2023
“Back then, at QEII, we were doing ‘breakdown maintenance’ only. But here [at QMMH] we do a lot of preventive maintenance.”
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Patient Double Room
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Hand washing stations; infection control
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Major improvements in pharmacy management
Lesotho Endline PPP Evaluation 3505/03/2023
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Improvements in Pharmacy
Real time inventory control Less waste of medication (lowers cost) More flexibility in ordering (ability to adjust to need) Less stockouts (ability to shift medications among
clinics or pharmacy locations) Less theft Better ability to track medication use (e.g. days on
antibiotic)
Lesotho PPP Endline Study 05/03/2023 36
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Information Systems
Extensive improvements in hospital data collection
State of the art computer systems for hospitals
Paper file, electronic record, and bukana
Lesotho PPP Endline Study 05/03/2023 37
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Fully Accredited by COHSASA through 2015Lesotho Endline PPP Evaluation 3805/03/2023
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Human Resource Management39Lesotho Endline PPP Evaluation
Hospital Staff (as of Dec 2012)Number of
QMMH StaffNumber of QE II
Staff%
DifferenceTotal 882 642 37%Sub-Categories Clinical Nature 563 345 63%Physicians 70 57 Dentists 5 6 Registered Nurses 284 130 Nursing Assistants 98 71 Other Clinical (i.e. Lab, Radiology etc.) 106 81 Non-Clinical Positions 319 297 7%Administrative Management 12 18 Support Staff 121 244 Catering 37 2 All Other 149 33
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Kronos “Hands-on” Biometric Scanner40
Time and Attendance Monitoring
Lesotho Endline PPP Evaluation 05/03/2023
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Nurses in the Neonatal Intensive Care Unit41Lesotho Endline PPP Evaluation
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Staff empowermentAt QEII my role was limited. I wouldn’t take on big decisions such as planning changes or developing the budget. But here I am involved with budgeting and recruitment of staff.
[Before,] they would give you a promotion but they didn’t help you learn your new responsibilities. By contrast, I knew what was expected of me by the time I started at Tsepong.
QEII was ruled politically…here I can talk to anybody and we can see how to address things.
Lesotho Endline PPP Evaluation 42
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Discussion and Recommendations
05/03/2023 43Lesotho Endline PPP Evaluation
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Discussion
Information systems and coding Indications for C-section High volumes, outpatient wait time, time to surgery Inexperienced staff, getting staff buy-in on changes Further analysis of referral systems, patient
satisfaction after discharge, staff satisfaction, and costs
Lesotho Endline PPP Evaluation 05/03/2023 44
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Conclusion Basotho in Maseru District have access to better
quality health care services, and people around the country have access to excellent referral services.
Health outcomes are much better at QMMH-IN, with about 693 fewer deaths per year, better infection control, greater amenities and more satisfied patients and empowered staff.
The Lesotho PPP may be a model for other low- and middle-income countries. This experience and lessons learned should be discussed broadly.
Lesotho Endline PPP Evaluation 05/03/2023 45
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Thank you!Kanako Yamashita AllenCassandra De SouzaCatherine O’FarrellYoko ShimadaLeslie VillegasToyin AjayiLauren BabichRich FeeleyDoug FieroMark HellowellKasey OliverKristin ShawNthati Lefuma, Moleboheng Mofolo, and the staff of LeBoHA in MaseruGlobal Partnership for Output Based Aid
Me Makhakhe, Ntate Leaooa, Dr. Letsie and other key informants from the Ministry of Health and GoL
Karen Prins and all of the staff of Tsepong working at QMMH and the Gateway, Likotsi, Mabote, and Qoaling Clinics