Health facilities that are properly staffed and equipped can provide high-quality care during the crucial moments surrounding labour and childbirth, for both the mother and baby. In fact, 75% of newborn deaths can be prevented with high-quality care, as can the majority of maternal deaths and stillbirths.(1) Continued emphasis on quality of care (QoC) in facilities is critical to advancing maternal, newborn and child health (MNCH). (2) In this process, stakeholder and community engagement is integral to ensuring that the care for women and newborns is of sufficient quality and according to their preferences and needs.
The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QOC Network) aims to reduce maternal and newborn mortality, and stillbirths, and to improve experiences of care. The QOC Network sets out to achieve a vision where every pregnant woman and newborn infant receives quality care throughout pregnancy, childbirth and the postnatal period. Currently, 10 countries across sub-Saharan Africa and South Asia have joined the QOC Network: Bangladesh, Côte d’Ivoire, Ethiopia, Ghana, India, Malawi, Nigeria, Sierra Leone, United Republic of Tanzania and Uganda.
In 2018, WHO conducted a scoping review that identified and reviewed existing guidelines, systematic reviews and primary studies around introducing stakeholder and community engagement into quality improvement (QI) processes. A comprehensive mapping exercise complemented the scoping review by collecting and synthesizing implementation tools used by different organizations to implement stakeholder and community engagement in QI initiatives. This module translates the findings of the scoping review and mapping exercise into actionable guidance and complements the implementation guide (3) developed by the QOC Network by expanding on the component of stakeholder and community engagement in QoC implementation (see Fig. 2).
This module aims to make stakeholder and community engagement an integral part of quality improvement (QI) initiatives, and suggests approaches to make stakeholder and community engagement comprehensive (engagement throughout the MNCH QI planning, implementation, monitoring and evaluation [M&E] cycle) and meaningful (supporting efficiency as well as partnership building and empowerment goals).
If stakeholder and community mapping and analysis, and the development of an engagement strategy are made an explicit part of QI initiatives, engagement is more likely to be systematic and meaningful in the governance structure and coordination mechanisms of the QI initiative, as well as in the implementation approach.
Readers of this module are encouraged to explore, test and learn from the guidance and resources offered, as appropriate and in line with stakeholder and community engagement processes already in place. This module will support the development of planned, meaningful and sustainable stakeholder and community engagement strategies and activities to make sure that every pregnant woman, newborn and child receives high-quality care in health services.
This module will support policy-makers and programme implementers who are interested in and/or (aim to) initiate and support stakeholder and community engagement in QI initiatives in MNCH across different levels. More specifically, it provides operational guidance to QI teams, which, in this module, refers to teams or working groups that take the leadership in stakeholder and community engagement in QI initiatives in MNCH. QI teams may be called by different names in various countries and may operate at different levels. They can be ministry of health (MOH) departments, teams and staff at the national level working on MNCH, community participation, community health, health promotion or QoC, or, as suggested in the implementation guide, technical working groups (TWG) at the national level overseeing QI initiatives. At the district and facility levels, this module may be used by QI teams, district health management teams, facility managers, and others involved in QI in MNCH. It is important to identify a group of individuals inside these structures (QI teams or TWG) who take the responsibility for stakeholder and community engagement activities, and who receive the mandate and resources to conduct (a selection of) steps identified in this module.
This module can be used to identify concrete steps and actions that need to be taken to support stakeholder and community engagement in QI for MNCH. Each section starts with a guidance section and is complemented by a list of resources that readers can consult to access more detailed “how to” guidance and examples.
Section 1 outlines the rationale for stakeholder and community engagement in QI initiatives in MNCH and provides some key concepts used.
Section 2 provides guidance to audiences at national, district and facility levels on building and strengthening stakeholder and community QI partnerships in MNCH in an explicit and systematic way. It supports the integration of stakeholder and community engagement in QI planning, as well as collaborative quality assessment. These strategies support the start-up phase described in the implementation guide (4) (see Fig. 3, steps 1–4).
Section 3 can be used by QI teams seeking to sustain stakeholder and community engagement by developing targeted information, communication and advocacy strategies. These strategies support the ongoing activities described in the implementation guide (see Fig. 3, step 5). (5)
Section 4 proposes approaches and tools to monitor, evaluate and document stakeholder and community engagement, in particular, QI partnerships. These strategies support the measurement, learning and refinement activities described in the implementation guide (see Fig. 3, steps 6 and 7). (6)
Box 1 summarizes the key concepts used in this module.
Quality of care (QoC) – QoC is defined as “the extent to which health-care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered”. (7)
Quality of MNCH care – This refers to “the degree to which maternal and newborn health services (for individuals and populations) increase the likelihood of timely, appropriate care for the purpose of achieving desired outcomes that are both consistent with current professional knowledge and take into account the preferences and aspirations of individual women and their families”. The WHO framework for the quality of maternal and newborn health care identifies three QoC dimensions (provision of care, experience of care, and resources) and eight QoC standards (see Table 2) that should be targeted to assess, improve and monitor care along two important and interlinked dimensions of provision and experience of care. (8) Stakeholders and communities are important participants in each of the domains and dimensions as service users, supporters and influencers.
Quality improvement (QI) – QI is “an organizational strategy that formally involves the analysis of process and outcomes data and the application of systematic efforts to improve performance”. (9) In this module, this concerns strengthening one or more dimensions of quality in order to improve MNCH care performance. This module uses the term quality improvement (QI) initiative to refer to improvement in policies, programmes, interventions and plans.
Stakeholders – Stakeholders are persons, groups, or institutions that are interested in or can influence QoC in an MNCH policy or programme, or who may be directly or indirectly affected by the process or outcome. (10) Stakeholders comprise multiple individuals and groups that could include community members, patients, health professionals, policy-makers, civil society, opinion leaders and the private sector. (11)
Community – These are “groups of people who share common interests, concerns or identities in settings that are defined by geography, culture, administrative boundaries or geopolitical region or that are identified with joint activities, such as work or recreation”. (12) “Community” may be conceptualized differently depending on the context and discipline. Examples are the “global health community” or the “MNCH community”, mostly referring to people who share a field of work. In literature on health service delivery, “community” is often ill defined, sometimes referring to groups of people living in a health facility catchment area or another administrative entity such as a county or district. In the field of community health, “community” often refers to women, men, family and community members (who are, in turn, ill defined). What matters in this module is that communities, or individual members of communities, may be stakeholders (or not). The guidance in this module aims to invite QI teams to break down the concept of “community” and identify communities that have a stake in QI initiatives.
Stakeholder and community engagement – This is “a process of developing relationships that enable stakeholders to work together and gain access to processes for assessing, analysing, planning, leading, implementing, monitoring, and evaluating, actions, programmes and policies to address quality of MNCH services”. (13)
Ending preventable newborn deaths and stillbirths. Geneva: WHO and UNICEF; n.d. (https://www.who.int/life-course/news/events newborns-stillbirths-75percent-preventable-lr-reduced.pdf ).
Chou VB, Walker N, Kanyangarara M. Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: a modeling study. PLoS Med. 2019;16(12):e1002990.
The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QOC Network). Improving the quality of care for maternal, newborn and child health – Implementation guide for facility, district and national levels. Geneva: WHO; forthcoming.
Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016.
Implementation guide for facility, district and national levels.
Stakeholder mapping guide for WHO MEC/SPR. Geneva: World Health Organization; n.d. (https://www.who.int/reproductivehealth/ stakeholder-mapping-tool.pdf ).
Adapted from: Glossary, Implementation guide for facility, district and national levels; and Spencer J, Gilmore B, Portela A. A mapping and synthesis of tools for stakeholder and community engagement in quality improvement processes for Sexual, Reproductive, Maternal, Newborn and Child Health, forthcoming.
Marston C, Hinton R, Kean S, Baral S, Ahuja A, Costello A, et al. Community participation for transformative action on women’s, children’s and adolescent’s health. Bull World Health Organ. 2016;94(5):376–82.
Adapted from Glossary, Implementation guide for facility, district and national levels; and A mapping and synthesis of tools for stakeholder and community engagement in quality improvement processes for Sexual, Reproductive, Maternal, Newborn and Child Health
THE ORIENTATION MODULE AT A GLANCE
SECTION 1. RATIONALE FOR STAKEHOLDER AND COMMUNITY ENGAGEMENT IN QUALITY IMPROVEMENT INITIATIVES