Note – content below is from an email update, September 2015
Why is measuring all the aspects of quality of care so challenging? Why do the majority of indicators to-date measure adherence to guidelines or instances of contact with the health system rather than content? What do recent developments offer for MNH services seeking to measure quality where this is ‘hard-to-capture’?
In this second informal update in relation to our recently launched learning resource on Quality of Maternal & Newborn Services, HEART shares contemporary examples of standards, indices and approaches being used to measure the ‘hard-to-capture’ aspects of the quality of care, for example during the peri-natal period.
#1) An indexed approach: The MEASURE programme – the Maternal Neonatal Program Index (MNPI) promotes a more comprehensive approach through the review and scoring of quality indicators across five main areas: policy, facility capacity, access, family planning and the care received. The approach canvases the opinion of experts (and as such is subjective) and aims to create a collective definition of broad standards and expectations.
#2) Standards-Based Management and Recognition: Jhpiego – the SBM-R approach, launched by Jhpiego in the 1990s and used in over 30 countries, continues to provide a practical and evidence based methodology for resource-poor settings; which can be led from facility level. Whilst the focus is on defining and attaining standards of care, the approach promotes “creative management of the change process, as well as active involvement of providers, clients and communities”.
#3) Developing global core indicators: WHO – a global standards approach to measuring MNH quality of care. A 2013/14 WHO consultation proposed core indicators which could be measured through established assessment tools, such as the Service Availability and Readiness Assessment (SARA) tool, and through additional quick surveys. The indicators provide a global standard but continue to focus on the availability of care against guidelines, rather than the quality of care.
#4) Improving quality assessment measures: Tripathi et al June 2015 – developing and validating an index that reflects both service delivery guidelines and empirically validated expert opinion. This study developed consensus on a range of dimensions of quality and promoted the expert review of care data from the Maternal and Child Integrated Progam (MCHIP). 20 essential actions for maternal and newborn care during the peri-natal period were identified. A subsequent pilot in Tanzania concluded that the tool his highly useable and that the indicators are streamlined, reliable, validated and potentially have multiple uses including research, supervision and verification of performance-based incentives programmes. There is a need for further testing but this approach is seen as a promising, and less resource intensive, addition to measuring and monitoring quality improvement strategies.
#5) Non-peri-natal care initiatives: while the focus has been on peri-natal care there is a growing recognition of the need to consider content, not just contact and coverage, across the continuum of care. For example, a recent analysis of ANC care in 41 countries which found failings in the provision of ANC services particularly in areas such as malaria prevention and iron-folate supplements (Hodgkins and D’Agostino, 2014).
- The resources highlighted above are just a selection of recent initiatives / publications – HEART does not endorse those mentioned.
- This update builds on the learning resource itself, which provided a discussion of some challenges of capturing and measuring the structural and process dimensions of quality. These include the use of facility based assessments, benchmarking against the UN signal functions and the use of surveys such as the MICS and DHS.