Health systems research
Improving the quality of routine health services in the Nouna district through an iterative process of policy and research over the
past 25 years
Rainer Sauerborn
Introduction
The discussion on the state and development of the routine quality of care delivered by health facilities in the Nouna health district has been both a policy and a research issue for the past 23 years. Recently, it has received, rightly so, more attention, since next to the district hospital, a research center, the CRSN, was created in the same district three years ago by the same ministry of health. This Center disposes considerable human and equipment resources, compared to the adjacent district hospital. For 2003 the CRSN intends to carry out clinical research together with Heidelberg University in an area with highly imperfect health services which raises, in addition, ethical issues.
This small report is intended to show that quality of care has been a constant concern of the last 23 years that I overlook the development of health services and it has been the intensive focus of research and of intervention deriving from this research. Both research results and policy efforts should be taken into account in the debate on two separate but linked questions:
1) How to improve the quality of routine health services?
2) Within theses routine health services: How to carry out clinical research which is both ethically and scientifically sound?
Period of 1975 – 1989
Intervention:
The MoH cooperated with GTZ and the German Volunteer Service (DED) in a project “Improvement of Rural Health Services” in 7 districts, of which Nouna was one. The project involved (i) the posting of DED physicians as counterparts of Burkinian physiciansin the Medical Centers and (ii) major renovation/ construction of dispensaries/maternities as well within existing Medical Centers. In the Nouna district, all dispensaries and maternities (CSPS) were renovated, the entire district hospital was renovated, the operating theater, pediatric, tuberculosis-leprosy ward and rehabilitation of poliomyelitis victims were newly built. Two generators were purchased (electrification of Nouna town was carried out as late as the year 2000).
Drugs covering about 1/3 of total consumption were provided free of charge by GTZ, the bulk of the rest had to be purchased. Only a minute fraction was provided by the Ministry of Health. The first attempts to standardise care (diagnosis and treatment decision trees) were introduced by the Burkinian and German Volunteer (DED) physicians. Regular supervision (monthly) was carried during the 14 year period.
An international evaluation of the joint GTZ/DED project was carried out in December 1982, led by Prof Diesfeld in conjunction with Dr. Pangu (Zaire) and Prof. Strobaant (University of Brussels, Belgium). The team analyzed routine health service data and observed health care delivery in a selective fashion and concluded that health services were seriously underutilized and might suffer from poor process quality in spite of the considerable efforts invested in improving the input dimension of quality of care.
The MoH authorized and requested a research project to verify these observations scientifically and analyze the factors that might influenze utilization and quality patterns. In 1985, a household survey and a systematic observation of general outpatient, under fives and maternity care was carried out, financed by the EU. The study team consisted of Prof. Diesfeld (PI), Adrien Nougtara and Rainer Sauerborn, supported by three Burkinian doctoral students. The study was carried out in the district of Solenzo which borders to the south on the Nouna district. The District Medical Officer of Solenzo at the time was Dr. Bocar Kouyate.
Research results:
Health services were organised according to provider convenience. They were fragmented in seven different clinics and were offered on different days forcing mothers to take their children almost constantly to the health centre. Service opening hours and waiting time were considered as extremely user unfriendly by the population. The human dimension of health care (accueil, communication, conseils) was also considered as poor.
On the effectiveness side there was a asynchrony between on the one hand the collection of correct risk factor information and on the other hand the lack of follow-up (weighing children without any consequences in the case of stagnant or decreasing weight, noting risk antenatal factors without the necessary steps to address this risk). Addition services were found extremely utilised when seen from the population bases: Only one in 8 people suffering from illness did in fact consult health services. Health services were reserved for diseases received as severe or mothers were the primary care agents of the population.
Policy conclusions for new quality interventions:
1) Establishing national standards of care and production of a manual of guidelines and training of health care workers to follow these guidelines.
After intensive consultation with numerous national authorities and services, the manual was completed in 1989 by the Burkinian team member under the editorial leadership of the national researcher, Dr. Nougtara.
2) Reduce drug costs through the estabilishment of a list of essential generic drugs.
This was accomplished in 1992.
3) Establish revolving drug fund at the district and CSPS level to facilitate access to low cost generic drugs and to generate resources to improve the functioning of health services.
The recommended policies were implemented in 1994 in the Nouna district. With funding of GTZ, an essential drug warehouse for the entire province was built next to the district health office, an initial stock was provdied by GTZ which was then resplenished using the revenue from drug sales to village pharmacies and to the hospital. Villages pharmacies in the vicinity of each CSPS were built and local drug fund managers trained. The revolving drug fund are managed by the communities of the CSPS catchment area.
4) Improving mothers skills to deal with common illnesses, recognise severe illnesses and refer them to the health centres.
The fourth proposal was implemented only in 2000: This was based on the finding that most health care was in fact provided by mothers at home. implemented in the following years were as the policy decided to improve both mothers as health care skills and the interface between services and those mothers was delayed due to various take holders until 2000 (see large EU-intervention project “Mothers’ Management of Childhood Malaria MAMOP” , carried out by the CRSN (PI), Muhimbili University (Tanzania) Karolinska Institut and Heidelberg University.
Period of 1990-99: Intervention research project: PRAPASS
Policies 1) through 3) were implemented by the MoH and evaluated through an intervention study, called PRAPASS (project de recherche-action pour l’amelioration des soins de sante). In the following we only report on the quality related research:
This policy had a definite success of making drugs available clarifying standards of care improving the knowledge of health staff. Drugs were confirmed to be available, manuals which had been compiled were also available at the nurses desk. Nurses new the procedures. However, it was observed that they did not follow in the daily clinical routine these standards of care. They rarely took a complete history and rarely examined the patients. The key finding of this study was that neither the level of the initial training of the nurse (state nurse or auxiliary nurse) nor the frequency of refresher-course, nor the existence of manuals and diagnostic and therapeutic standards of care were correlated in any way with the quality of care observed. The only variable which was linked with quality was the individual nurse, which pointed to issues of motivation as the main remaining cause of bad quality of care. The study confirmed that the equipment with basic tools such as stethoscopes, tensiometers, speculae for vaginal exams etc. were available in most cases.
The focus of attention for improving quality of care in therefore shifted from inputs (drugs, equipment, infrastructure, training, supervision) to the process of care, more precisely the motivation of staff.
The CRSN: 1st phase 1999 through 2000:
Implementing Total quality management in peripheral health services (CSPS) and the district hospital (CM)
With funds from TMH and from a private foundation, the modern tools of quality management were implement in the Nouna district in 1997 through 1999 with the assistance of a team of health care specialists from neighboring Niger who had had a lot of experience with adapting TQM techniques to similar local conditions. The team Niger team consisted of US-American quality of care specialists (USAID) and Nigerien health staff with many years of implementation experience.
Quality circles were established, their members trained in situation analysis problem solving. This interventioned was supported from money from the THM. Rob Baltussen , also paid by TMH, was posted to implement this for two years in Nouna. Two studies emanated from that period one of the perception of quality by the population (Baltussen et al 2001). This paper found huge differences in the perceived quality of various CSPS and the District Hospital. Perceived quality was inversely related with the resources those facilities consumed. For example the district hospital of Nouna had the poorest scoring by the population on all accounts although it consumed about half of the entire district health budget.
A study on the implementation quality of this total quality management program (Some et al, 2002) showed that by and large, the total quality management procedures had been satisfactorily implemendted. However some shortcomings were observed in the composition of quality circles: particulary at the Nouna district hospital, the group consisted largely of civil servants, mainly nurses. Women were underrepresented in all quality circles.
The CRSN: current policies and research: TQM, shared care, staff motivation
A large new project funded by the EU together with Karolinska Institute (Stockholm) and Muhimbili University, Tanzania was proposed (Dr. B. Kouyate being the principal investigator) and won. It sets out to test a two-pronged approach to improving the quality of care, using malaria management of under fives’ as indicator disease. The first part was improving the piloted total quality management approach of all health services in the Nouna district. The second part aimed at strengthening mother’s health care skills (this had been a proposed in 1989, see above under 4) “policy conclusions of the 1979-89 period”. Under this policy, women’s groups were to be the intermediary between mothers who were to be trained in recognizing and treating simple malaria attacks of their children. It was hypothesized that TQM and closer linkage and interaction between population and nurses would lead to a better and more user friendly operation of health services. Quality indicators were identified and are currently being followed. Both the SFB project D2 (community based insurance) and the EU-project “Management of Childhood Malaria (MAMOP) project” use these policy tools.
It is planned that through the resources generated by the community based insurance which will be equally retained both at the village level and at the health service level. Performance based incentives will be offered to local health stuff and this as other studies have shown is dissipated to improve the process quality of care. At the same time we will start to a relate quality of care with health outcomes, in a first approach these outcomes will be severity and duration of malaria episodes as well as case fertility.
An anthropological study on the motivation of health staff is currently completed and will help to fine-tune the strategies to motivate health care staff through pecuniary and non-pecuniary means
Conclusions
The activities described above show that improving the quality of care has been a focus of intention for both policy makers and researchers for the last 25 years. It is an extremely difficult problem to tackle and is resistant to simple uni-dimensional solutions such as pouring inputs such as equipment into health service, however well-meaning such approaches are. The input-centered based approach had been tried by GTZ for decades without palpable result. While it is obvious that an essential level of facilities, infrastructure, equipment and consumables is a necessary, it is not a sufficient condition for improving the quality of care. The challenge is to find out new strategies to change the institutional framework and the incentives under which health workers operate, to bridge the gap which often separates the health care providers from the communities they serve.
With this report I wish to provide information on the efforts on the part of the MoH, donors, the research team, the CRSN and the health staff to improve quality of care. It remains a challenge both for policy and research and it is tackled actively under current research and policy arrangement. This is important to understand and appreciate, as the CRSN and the health district prepare to introduce clinical research in the district.
Publications on quality of care
(in chronological order):
Sauerborn R, Nougtara A, Bidiga J, Sorgho G, Tiebelesse L, Diesfeld H‑J. (1989) Assessment of MCH‑services in the district of Solenzo, Burkina Faso - II) Acceptability. Journal of Tropical Pediatrics 35 (Suppl. 1):10‑13.
Sauerborn R, Nougtara A, Bidiga J, Sorgho G, Diesfeld H‑J. (1989) Assessment of MCH‑ services in the district of Solenzo, Burkina Faso - III) Effectivity of MCH‑services in detecting of and caring for mothers and children at risk. Journal of Tropical Pediatrics 35 (Suppl. 1):14‑17.
Reerink I, Sauerborn R. (1996) Quality of primary health care in developing countries – recent experiences and future direction. International Journal of Quality of Health Care 8(2)131-139.
Krause,G., Schleiermacher,D., Borchert,M., Benzler,J., Heinmüller,R., Ouattara,K., Coulibaly,S., Diasso,I., Ilboudo,A., & Diesfeld,H.J. (1998). Diagnostic quality in rural health centers in Burkina Faso. Trop Med Int Health, 3, 100-107.
Krause G., Benzler J., Heinmüller R., Borchert M., Koob E., Ouattara K. Diesfeld HJ (1998). Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso. Health Policy Plan, 13, 159-166.
Krause, G., Borchert, M., Benzler,J., Heinmüller, R., Kaba, I., Savadogo, M., Siho, N., & Diesfeld, H.J. (1999). Rationality of drug prescriptions in rural health centers in Burkina Faso. Health Policy Plan, 14, 291-298.
Krause G, Sauerborn R. (2000) Community-effectiveness of care - the example of malaria treatment in rural Burkina Faso, Annals of Tropical Pediatrics, 7:99-106.
Sauerborn R. (2002). Low quality of care in low income countries – is the private sector the answer? Intl. J Qual Care. 13(4):281-282.
Baltussen RMP, Yé Y, Haddad S, Sauerborn R. (2002) Perceived quality of care of primary health care services in Burkina Faso. Health Policy and Planning. 17(1)42-48.
Baltussen R and Yé Y. (2005) Quality of Primary Health Care services as perceived by Users and Non-Users in Burkina Faso. International Journal for Quality in Health Care (Accepted).
Somé F, Sax S, Marx M, Baltussen R, Sauerborn R. The implementation of quality assurance in district health services in Nouna, Burkina Faso. Submitted.
Becker K, Some F, Sauerborn RLow quality of malaria care in rural health facilities in Burkina Faso. Submitted.