Test users in Jharkhand, India, provided input on an early version of the Together for Her Health platform, designed to empower women and elevate their voices around care quality. ©MSD for Mothers
By Mary-Ann Etiebet, MSD for Mothers
Every week, Dr. Priti Gade, an obstetrician-gynecologist in Uran, a small coastal town east of Mumbai, sits down in front of her computer, logs into the Together for Her Health website and checks to see what her patients are saying about her.
From a digital dashboard, Dr. Gade can view how her patients have (anonymously) rated the care they received while giving birth at her hospital, a 15-bed private facility she founded with her husband and partner, an orthopedic surgeon, in 2005. She sees how many stars the hospital has earned on nine different aspects of maternity care, from cleanliness to family planning guidance to counseling on postpartum danger signs, among other quality indicators based on WHO standards. She reads the comments section, where patients can raise other issues.
And then Dr. Gade calls a staff meeting to discuss the feedback. “We have a good rating – 4.5 out of 5 stars overall, last I checked,” she says. “But sometimes, when we don’t get high marks on something, I flag it for the staff, so we can work together to improve our services. It’s important.” For example, when Dr. Gade spotted a few low scores on postpartum family planning counseling, she organized a shift in approach. “We learned that we need to spend more time talking to the patients, to make sure they understand the methods that are available, the benefits of proper birth spacing for both the mother and the baby. We need to make sure everyone on staff is properly informed, and do a better job relaying the information.”
Dr. Gade registered Gade Hospital with the Together platform about a year ago, joining soon after it launched in November 2017. Nearly 700 other private providers in Maharashtra and Uttar Pradesh states have also linked their online profiles to the ratings system. More than 20,000 reviews have been submitted so far.
“We are starting to see new patients come in who found us by searching the Together website,” Dr. Gade says. “We are hoping that as awareness grows, more and more patients will give ratings, and more providers will sign up, not wanting to be left behind. We need this. Empowering women, enabling them to make more informed choices about their care – that’s what will help drive quality improvement in India.”
And that is precisely the point: When MSD for Mothers partnered with Almata (a division of Avegen Pte Ltd.) to create Together, we envisioned a platform that would leverage the Internet and mobile technology to help ignite a quality movement – taking a consumer-centric, “total market” approach. We would focus on private facilities, which have been largely excluded from other quality improvement initiatives, and where up to half of low- and middle- income women in India go to give birth. (The government of India’s My Hospital website collects feedback on public hospitals, and it is not specific to maternity care.) We would provide an example of how we can align incentives, among both patients and providers, to promote transparency, accountability, care quality and ultimately better health outcomes – all critical if India is to achieve SDG targets for reducing maternal mortality.
A year into Together’s initial deployment, we’re seeing clear signs that the approach is working. A preliminary analysis by the Together team, comparing average performance ratings for hospitals prior to registering with the Together site vs. three months after registration, found a clear jump across the board – suggesting that hospitals are taking the feedback seriously, and acting on it. “The data indicates that the feedback is getting back to the facilities and leading to change,” says Sumiti Saharan, Design and Research Director for Avegen. “It’s a gorgeous loop we’re seeing.”
Registering with Together is strictly voluntary – a chance for providers who are committed to quality to raise their hand and embrace accountability to their patients – and perhaps even gain a competitive edge in a crowded market. Notes Saharan: “Together is a choice for these providers, and they come onboard because they are getting assessed on criteria that really matter, and getting feedback in a way that is objective, and also actionable.” Addressing many of the issues related to the nine quality indicators, it’s worth noting, comes at little or no cost, and so feasible even for the smallest facilities to implement.
Dr. Ravi Kulkarni has been in private practice in Pune for 38 years, delivering about 50 babies a month. Like Dr. Gade, he checks his Together dashboard every week. He says having a third party collect feedback means patients will be more forthcoming; honest reviews are more useful to the providers and to the expecting mothers comparing facilities and weighing their options. (Providers who register with Together do not control which reviews get posted.)
“Whether it’s good or bad feedback, one has to be open, and willing to hear it,” Dr. Kulkarni says. In response to the reviews that have come in, his staff has become more proactive on kangaroo care (facilitating the recommended skin-to-skin contact between mother and her newborn) and on supporting early breastfeeding. “We’re putting the baby to breast immediately after delivery now,” he says, rather than waiting until the mother has been transferred from the labor ward to her room. “That is one big change we have made.”
Going forward, we will be working with our partners to deepen Together’s reach within its two pilot states while looking to expand into other parts of India. The hope is that as the platform gains traction among both mothers and providers, engagement will build naturally, increasing competition among providers on the basis of quality and laying a foundation for meaningful – and sustainable – impact.
The rate at which the reviews are coming in – roughly 2,000 a month and climbing – is encouraging. So is the favorable response we’ve been getting from women regarding the website’s content and general approach.
Lina Wadile from Navi Mumbai tells us she found the quality indicators immensely helpful – bringing clarity to some of the “myths and fears” around childbirth, “things you can’t Google.” When Wadile became pregnant with her first child in 2017, she had recently moved to a new city with her husband, far away from family and friends; having an online resource gave her confidence. She agreed to submit a review of the hospital where she gave birth to a son, so that others might benefit from her experience. “It is comforting to have the information,” she says. “When choosing a hospital you want to know what you are getting into.”
Bhumi Prajapati of Gujarat, a new mom with an 8-month-old daughter, discovered Together through Facebook. What she appreciates most about the platform, she says, is that the information is evidence based, an important differentiator given all the conflicting advice that is out there. As a doctor herself – she works in the emergency department at a hospital in Surat – she sees an advantage to the feedback loop, with its direct line to those in charge. “Management will know what they are lacking, and what they can improve.”
Facilities that have identified gaps in care can also work to improve quality through Manyata, a national program MSD for Mothers launched in partnership with Jhpiego and the Federation of Obstetricians and Gynecologists Societies of India (FOGSI). Through Manyata, facility teams can participate in trainings and capacity building activities, and work to fulfill other requirements for national certification and accreditation – and further distinguish themselves from competitors.
Both the Together for Her Health and Manyata initiatives demonstrate effective ways to harness the capacity of the local private sector to advance quality while also keeping quality at the forefront of Universal Health Coverage agenda. With Together, we are elevating patient voices and empowering women; we are also gaining valuable insights that can help inform the new global What Women Want campaign.
At scale, mechanisms like Together could ultimately help transform design and delivery of maternal and reproductive health services. We look forward to working with national and global health advocates and collaborating across sectors to reinforce this women-centered approach – to figure out how to scale it, replicate it and embed it into broader health systems – to bring us closer to the day when all women everywhere have access to quality care, wherever they seek it.
Mary-Ann Etiebet is the Lead and Executive Director of MSD for Mothers, a $500 million global maternal health initiative funded by Merck & Co., Inc., Kenilworth, NJ, USA, working to help create a world where no woman dies giving life. Visit http://reports.msdformothers.com/ to learn more about how we are partnering to harness digital technology and drive innovative solutions to improve maternity care and family planning services for women and girls in need.