Recording and materials from the webinar on Quality improvement that works: mentoring, supervision and involving the community Lessons from the Maternal and Neonatal Implementation for Equitable Systems project in Uganda

Doreen Anican (20 years old) breastfeeds her newborn baby at Maternal Child Health in Parombo Health Centre III in Nebbi District in the West Nile region. Uganda. ©UNICEF/Noorani
 
1.11.2017

The Network for Improving Quality of Care for Maternal and Newborn Health (Quality of Care Network), organized a webinar to share some of the lessons from the Maternal and Neonatal Implementation for Equitable Systems (MANIFEST) project which the Makerere University School of Public Health run in 2012-2015.

Listen to the webinar recording here

The study was conducted in three districts in Eastern Uganda to help reduce maternal and neonatal deaths through the use of a participatory action research approach.

The speaker, Dr Suzanne Kiwanuka, a senior lecturer at Makerere University School of Public Health Kampala Uganda and a health systems and policy expert explained how this approach involved communities, district and facility management simultaneously. She highlighted how mentoring and supervising quality improvement teams were key in seeing quality improvement take hold in a facility. 

See below the questions that participants asked during the webinar, aswell as Dr Kiwunaka's answers.

Read more:

The MANIFEST project has published a Supplement in Global Health Action. The lessons of the project are also documented in a series of nine Briefing Papers and a documentary.

This was a webinar in the special country highlights series of the Quality of Care Network. See here the details on all webinars in the series on capacity building for improving quality of care in health facilities: http://www.qualityofcarenetwork.org/about/network-activities

 

                                                                

Comments

Great presentation Suzanne! CSI is a PMNCH member. We do work in Uganda (Wakiso, Mukono) mostly at the grassroots level with Village Health Teams and Community Leaders to increase and improve maternal-newborn health--delivery with a skilled birth attendant on time, maternal health education, we engage men, provide obstetrical kits, and more. What opportunities are there to collaborate to strengthen the demand side? Would the collaboration have to be in one of those three districts? Thank you.

ANSWER

The MANIFEST project ended in 2015, although the team is still doing some work in those districts. Yes collaboration is indeed possible and can be discussed.

What strategies are incorporated to retain midwives once they've been recruited?

 

ANSWER

Most midwives are public servants, apart from those in the private not for profit. We did not make any efforts to retain the midwives but all of them stayed. Something else we did was to recognize good performance at bi-annual HW symposia. Health workers and facilities were awarded. Facilities were awarded based on the scores they got during the support supervision while health workers were awarded based on the scores by their own colleagues.

Do you have information on the quality of implementation (care)? For example, you have documented that newborn examination was carried out but how did you document that it was done in an appropriate manner and key issues were not missed?

ANSWER

Observation of quality of care was done during the mentorship visits. Mentors highlighted gaps whenever they visited each facility and these gaps informed the purpose of the mentorship visits.

Do you also have data to show improvement in outcomes at the facility level?

ANSWER

Outcomes are published in the supplement. Look for the paper on effects.

If 12 facilities received 2-3 day monthly mentorship visits, does that mean that mentors spent 2-3 days at EACH facility? Or did they spend 2-3 days to visit 12 HFs?

ANSWER

2-3 days were spent at each facility. There were two teams in each district initially then and each team mentored one facility (that means 2X3) facilities were mentors in the first round. Later these teams plus some newly mentors HWs moved to 2 more facilities in the same district (cascade). Giving another 6 facilities mentored for the rest of the project.

Thank you for a very interesting presentation. Did you experience any challenges with regards to staff attitude towards the quality improvement initiative? If yes how did you address these?

ANSWER

Staff attitude was present in terms of medical officers not joining the rest of the HW for mentorship. We considered making them a part of the mentorship team.

Other instances were community reports in one facility where the health worker was often drunk. This health worker was severely reprimanded and transferred to a facility near the district health office and closely supervised by the DHO.

The importance of mentorship seems critical, how do we institutionalise this function and what was the profile of the mentors used?

ANSWER

External mentors were consultants from the national hospital and some from regional hospitals. They were joined by senior midwives, nurses and doctors from within the districts. Perhaps working through the professional associations this can be made part of the job responsibility of the senior health worker but ideas are invited.

Need an idea on a) sustainability b) cost c) role of internal/external mentorship

ANSWER

Peter could answer this, he was part of the team. What proposals do you have?

 

Excellent description of the intervention - thank you. This is important as it describes a skills building model that can improve maternal and newborn outcomes. Did you notice some processes beyond knowledge and skills building, that needed to be improved, as an add on intervention to the mentorship? This may have been beyond the scope of your study, but I am interested in your insight.

ANSWER

One of the things that emerged was leadership at facility level. The need for HWs to take initiative and request for help based on the challenges instead of merely complaining and giving up. In one district we told the health workers one thing they could do is to put together a document making a case for the assistance they needed. This facility needed a waiting shade for mothers and they put together a proposal with a budget which they presented to partners. This facility was able to obtain resources from development partners to build this waiting shade over a period of one year based on their proposal. We noted they often complained about what they did not have without presenting a solid case on what they need or proposing solutions which could be funded. This capacity to lead needs to be build more.

Were the facilities primarily health centers; or did you include hospitals?

ANSWER

Two hospitals and one health centre IV were included. Results are not presented at facility level although we do have data on changes at facility level.

Thanks for the interesting presentation. I may have missed it but what was the effect on mortality and morbidity?

ANSWER

Please check the paper on effects in the supplement.

If I understand correctly, the regional mentors were supported by MANIFEST funds, but the internal mentors were employees of the facilities. Is this a sustainable model? Will the facilities continue to support the time and effort of these individuals over time? Will facilities continue to support the collection of data for M&E?

ANSWER

Both external and internal mentors were supported by MANIFEST to do the mentorship. This was intended to build capacity of internal mentors so that there is a core mass of mentors in each district. We had an exist dialogue with the districts on sustainability and one of the proposals was to allocate a mentor tied to different facilities and to continue supporting this function. We are yet to followup what is being done.

The process appears to have been very resource intensive although the outcomes are very encouraging. Please comment on sustainability and scalability of this model.

ANSWER

This model is sustainable and scalable to the extent that district authorities are able to utilize the capacity built within the district but also to lobby for resources to maintain it. Tagging senior health workers to each facility could be a model to consider.

Do you have an established training program for supportive supervisors that you would be willing to share?

ANSWER

Support supervisors were trained using ALARM protocols and newborn survival protocols. They were also trained on basics of supervision. These are available.

How did  improved service provision affect on staff workload, morale amidst low staffing levels? Could the increase in one service provision mean neglect or limited capacity to provide the whole package? For example, why were there reductions in HCT testing?

ANSWER

The intervention was not designed to track this but perhaps records can be reviewed to assess these effects. These were not outcomes we set out to assess so we did not.

On mentorship, were the mentors from the same study districts? I wonder how this would affect their duty stations re: absenteeism

ANSWER

Mentors were from the same study district and from higher level facilities which have more than one midwife. Senior nurse. These were off duty for this purpose based on pre-scheduled programs. The mentorship schedules were pre-arranged by the district and replacement staff were available. (please note, no all health workers away from their duty station are absent. Health workers have off-duty days which they can use for other activities). Other members were from the district health team some of whom are not attached to facilities.

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