1. Accelerating Spread of Community-Based Strategies to Reduce Maternal, Newborn and Child Health Challenges in Ghana by Nana A. Y. Twum-Danso, MD, MPH Director, Project Fives Alive! Institute for Healthcare Improvement 5 th Annual International Conference of the African Science Academy Development Initiative La Palm Royal Beach Hotel, Accra, Ghana November 10-11, 2009

2. Presentation Outline Background Successful Community- Based Strategies Summary

3. BACKGROUND

4. Background (1/6): Aim of Project Fives Alive! Assist and accelerate Ghana's faith-based and public health services efforts to achieve MDG4 through the application of quality improvement methods

5. Community Level 1. Low/no risk awareness, prevention & management 2. Low valuation of women & children’s lives 3. Lack of financial means and/or health insurance 4. Distance from health services 5. Unattractive health services (staff attitudes, cultural incompatibility etc.) Background (2/6): Drivers of Under-5 Deaths in Ghana Health Facility Level 1. Lack of patient-centeredness in design of health services 2. Irregular and/or inappropriate preventive care 3. Late and/or inappropriate therapeutic care 4. Unreliable referral system from clinics to hospitals 5. Inequity in health services provision 6. Unreliable generation & movement of health information

6. Resources  Knowledge & Training  Systems Approach  Background (3/6): Enablers of Under-5 Survival in Ghana

7. Background (4/6): QI Strategies - The Model for Improvement Source: Associates for Process Improvement Method of continuous quality improvement Provides a framework work for developing and testing change ideas, learning and re-design Emphasizes small changes that are non-threatening and non-disruptive Relies on input and ideas from frontline providers

8. Background (5/6): QI Strategies – Improvement Collaborative Network Start Small, Accelerate Learning & Scale-up Rapidly Wave 1 26 clinics & 2 hospitals from 4 districts/dioceses Jul’08 to present

9. Care Pathway Background (6/6): Focus of QI Work

10. SELECTION OF SUCCESSFUL STRATEGIES

11. Antenatal Care: Activate CBVs to identify pregnant women in community early, provide health education, refer to clinic for ANC, midwife follows-up NHI free for maternity & early infant care; small scale testing of pregnancy registers

12. Skilled Delivery: Engage TBAs to accompany labouring women to health facility; TBA can stay and serve as delivery companion

13. Skilled Delivery: Engage chiefs & elders on risks of labour and delivery & enlist their help in promoting skilled delivery

14. Skilled Delivery : Video show in community on risks of unskilled delivery followed by Q&A session and health promotion

15. Skilled Delivery : Mobile telephone contact between labouring women and health staff for transport or domiciliary midwifery

16. Postnatal Care : Home visits by health staff on Day 1 or 2 for neonates born at home and home visits on Day 6 or 7 for all neonates

17. Postnatal Care : Home visits by CBVs on Day 4 to screen for danger signs and remind mothers to follow up at health center on Day 6 or 7

18. Data were collected on each change idea tested 6 to 12 months of baseline data and at least 6 months of post- intervention data Used time-series analysis to determine successful change ideas. Developed strict criteria for determining successful change ideas: Change Package: Development of a change package for scale up ScoreDefinition 0No evidence or suggestions of improvement 1 Suggestions of improvement but not enough time to meet test of evidence 2 Evidence of improvement but not sustained OR not enough time to assess sustainability 3Evidence of improvement which has been sustained

19. Change Package Scaling Up Change Package Sept’09 to Jun’11 Wave 2 ~300 QI teams from 38 districts

20. SUMMARY

21. Local knowledge, innovation and testing of changes at the community level can reduce delay in seeking care for MNCH Local generation and use of data key to: – Frontline health provider empowerment to develop and test changes iteratively for continuous improvement – Improving data quality from primary sources Processes across care continuum can be accelerated with Improvement Collaborative Network model through: – peer-to- peer learning – deliberate spreading of successful change ideas/best practices Change package can facilitate spread of local successes or best practices on a large scale to achieve higher coverage and improved health outcomes in non-innovation sites Summary

22. Can the achievement of MDG4 in Ghana be further accelerated? We believe we can!

23. Acknowledgements Team – George B. Akanlu – Isaac A. Amenga-Etego – Ireneous N. Dasoberi – Solomon A. Atinbire – Phoebe Bala – Francisca Bagna – Chrysanthus Kubio – James Tobiga – Pierre M. Barker Institutions – Ghana Health Service – National Catholic Health Service – Institute for Healthcare Improvement – Bill & Melinda Gates Foundation