1. 1 Better health processes and outcomes: How do we get there? Maina Boucar, MD, MPH USAID – Applying Science to Strengthen and Improve Systems Regional Office for Francophone Africa Niamey – Niger

2. USAID Applying Science to Strengthen and Improve Systems 2 Hausa Proverb “ The world is like a pregnant woman; you never know what will emerge.”

3. USAID Applying Science to Strengthen and Improve Systems 3 In Niger… A woman dies every 2 hours of pregnancy/ childbirth complications A woman faces a one in seven chance of dying from pregnancy-related complications during her lifetime Maternal Mortality Ratio: 700/100,000 (DHS 2006) Post-partum hemorrhage is the single largest cause of maternal mortality in Niger (29%) BP linked conditions are the 3rd cause of maternal mortality 40 % of children suffer from chronic malnutrition 50% of early childhood deaths associated with malnutrition WHY?

4. USAID Applying Science to Strengthen and Improve Systems 4 Why do we fail to address these issues? Evidence based high impact interventions (examples) PEE screening and case management Infection Prevention AMSTL, ENC Blood management

5. USAID Applying Science to Strengthen and Improve Systems 5 USAID-HCI Niger USAID-HCI assisted MOH in 48 MOH sites in 7 of 8 regions Maternal Newborn Care: AMTSL/Essential Newborn Care: 33 MOH sites; 64% districts; 31,085 births 2008 Pre-eclampsia/Eclampsia: 31 MOH sites; 119,045 patient contacts/year Child Health: IMCI and Malnutrition 15 MOH sites FY08 Budget: $800,000; 4 staff

6. USAID Applying Science to Strengthen and Improve Systems Program Impact: Niger Reduction in Post-partum Hemorrhage 6

7. USAID Applying Science to Strengthen and Improve Systems Program Impact: Niger Improving quality of pre-eclampsia/eclampsia care 7 Changes implemented: Systematic screening at every contact Organization daily tasks to prevent stock outs Standardized emergency case management eclampsia Standardized referral protocols

8. USAID Applying Science to Strengthen and Improve Systems 8 Site QI Team

9. USAID Applying Science to Strengthen and Improve Systems Examples of Changes: Newborn Care Companion in labor Thermal control 1 st hour Breast feeding supportLocal warming table

10. USAID Applying Science to Strengthen and Improve Systems Examples of Changes: AMTSL for Prevention of PPH AMTSL stamp Cooler for Oxytocin Infection Prevention MaterialsDesignated Delivery Areas

11. USAID Applying Science to Strengthen and Improve Systems Sustaining gains for active management of the third stage of labor (AMTSL) in 20 sites in Niger

12. USAID Applying Science to Strengthen and Improve Systems Mali: What are we trying to accomplish and at what scale in 2009-2011? Mali Kayes Region USAID HCI Apply lessons learned and best practices from Niger’s experience

13. USAID Applying Science to Strengthen and Improve Systems Average # monthly births: 1,024 AMTSL coverage and post-partum hemorrhage rates in 41 target facilities, Kayes & Diema Districts, Mali, Oct. 2009 – Dec. 2011 Mali: AMTSL & post-partum hemorrhage management 13

14. 14 The Science of Improvement A structured approach to deliver evidence based high impact interventions at scale

15. USAID Applying Science to Strengthen and Improve Systems Different Ways by Which Quality Can Become Better Through accumulation of knowledge and experience over time Through trial and error Through advances in science and scientific experiments By coincidence On the basis of improvement science

16. USAID Applying Science to Strengthen and Improve Systems The Framework for Health Care Quality Improvement

17. Associates in Process Improvement 17

18. USAID Applying Science to Strengthen and Improve Systems Principles of Improvement “Fundamental Concept of Improvement: “Every System is perfectly designed to achieve exactly the results it achieves” Principles of Improvement: –Understanding work in terms of processes and systems –Implementing high impact interventions by redesigning processes –Process redesign by teams of front-line health care providers supported by District and Regional Health Management Teams –Focusing on patient needs and preferences in the redesign of processes –Testing changes to see if they yield improvement –Data management by teams of health care providers for continuous improvement –Shared Learning facilitated process by which multiple teams learning from each other 18

19. USAID Applying Science to Strengthen and Improve Systems Employee Engagement (…or lack thereof)