The countdown for the Millennium Development Goals: can improvement science help achieve the MDG targets?

Transcription

1 International Forum on Quality & Safety in Healthcare Palais des Congrès, Paris, April 8 11 SESSION A1: CHANGE ON A GLOBAL SCALE The countdown for the Millennium Development Goals: can improvement science help achieve the MDG targets? M. Rashad Massoud, MD, MPH, FACP Director, Senior Vice President, Quality and Performance Institute University Research Co., LLC Center for Human Services, USA 1 Objectives After this session, participants will be able to: Articulate the MDG goals and their importance to global health Discuss the status of achieving the MDGs globally Outline the challenges in attaining the MDG targets Explain how improvement science can contribute to achieving the MDG target 2 science help achieve the MDG targets? 1

2 Millennium Summit 2000 The Millennium Development Goals 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria, and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development science help achieve the MDG targets? 2

3 Health MDGs 4, 5 and 6 Source: United Nations Health MDGs Scorecard GOALS AND TARGETS Northern Africa Sub- Saharan Eastern South- Eastern Asia Southern Western Oceania Latin America & the Caribbean Caucasus & Central Asia 6 Source: United Nations 2013 science help achieve the MDG targets? 3

4 People living with HIV are surviving longer Source: United Nations What is the problem: WHO The reality is straightforward. The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and at an adequate scale. Margaret Chan Director General World Health Organization 8 science help achieve the MDG targets? 4

5 McGlynn et al. NEJM The quality of health care delivered to adults in the U.S. 439 indicators of clinical quality of care 30 acute and chronic conditions, plus prevention Medical records for 6712 patients Participants received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic: 56.1%; Preventive: 54.9%) Conclusion: The defect rate in the technical quality of American health care is approximately 45% 9 The Issue of Quality in Health Care Between the health care we have and the care we can have lies not only a gap, but a chasm The problems come from poor systems not bad people 10 science help achieve the MDG targets? 5

6 What is the problem: World Bank The enormous investments that have been made in global health should have led to what we might have called a science of implementation and execution We have just not focused on the enormous complexity of delivering health care in a way that keeps people healthy h Jim Kim President, World Bank 11 USAID Health Care Improvement Project FY2014 Activities 12 science help achieve the MDG targets? 6

7 USAID Applying Science to Strengthen and Improve Systems Project FY2014 Activities 13 Contributions to Achieving the MDGs in FY14 MDG Countries where ASSIST and HCI activities contribute in FY14 Haiti, Kenya, Malawi, Mozambique, Nigeria, Tanzania, Uganda Haiti, Kenya, Malawi, Mozambique, Nigeria, Tanzania, Uganda Afghanistan, Georgia, Kenya, Malawi, Mali, Mozambique, Nigeria, Tanzania, Uganda 14 Afghanistan, Burundi, Cote d Ivoire, Georgia, Haiti, India, Kenya, Madagascar, Malawi, Mali, Mozambique, Nicaragua, Nigeria, South Africa, Swaziland, Tanzania, Uganda Afghanistan, Botswana, Burundi, Cote d Ivoire, Ethiopia, Georgia, India, Indonesia, Kenya, Madagascar, Mali, Nicaragua, South Africa, Tanzania, Uganda, Ukraine Botswana, Burundi, Cote d Ivoire, Ethiopia, Haiti, India, Kenya, Lesotho, Malawi, Mozambique, Nicaragua, Nigeria, Pakistan, South Africa, Swaziland, Tanzania, USAID Uganda Applying Science to Strengthen and Improve Systems science help achieve the MDG targets? 7

8 Achieving System Level Results Will New possibilities Build confidence Ideas Sequencing and tempo Execution Execution Achieve breakthrough goals Spread and sustain Provide leaders for large system projects Manage local improvement Provide day-to-day leaders for micro systems Develop human resources science help achieve the MDG targets? 8

9 Integrating Content and Organization of Care 17 Example: Maternal Mortality Initiative Botswana Goal: Reducing Maternal Mortality to Achieve MDG Target MDG Target: science help achieve the MDG targets? 9

10 Botswana: Features of Execution Strategy for Achieving Strategic Goals at Scale Strategy to reach the whole country -- all at once Aligned with MOH lines of authority and execution of everyday work Builds on the lessons from HIV/PMTCT success Botswana: Elements of Strategy for Achieving Strategic Goals at Scale A small number of strategic goals (1-2): Improve management of maternal complications and reduce maternal deaths Portfolio of Activities to Achieve Strategic Goals: Bridging gaps in clinical care Addressing systemic issues Deploying Resources to Achieve Strategic Goals: National level District level Facility level Establishing Systems to Achieve Strategic Goals: Data (process/ temporary vs. on-going) Learning (Extension agents and convening primary health care support for districts) Oversight and Support (National, District and Facility) science help achieve the MDG targets? 10

11 Portfolio of Activities to Achieve Strategic Goals: Overcoming Gaps in Clinical Care for Leading Maternal Complications Leading Causes Maternal Mortality (proportions vary by year) PPH Eclampsia Puerpal sepsis Abortion-related HIV-related Obstructed Labor Other (including respiratory, cardiac, protozoal, hepatitis, ectopic, embolism and other indirect causes) Source: Health Statistics Reports, Botswana Central Statistics Office, Portfolio of Activities to Achieve Strategic Goals: Overcoming Gaps in Clinical Care for Pre-eclampsia / Eclampsia (see attachment) Facility Level Quality of Care Gaps High Impact Interventions Referral Hospital Maternity Primary & District Hospital Maternity -Inaccurate measurement BP &/or failure to monitor BP every 4 hours in labor and post-partum per protocol -Failure to begin MgSO4 for any DBP > 110 and 3+ proteinuria or DBP > 90, 2+ proteinuria and associated symptoms -Non-adherence with MgSO4 treatment guidelines -Failure to monitor for MgSo4 toxicity (respiratory, urine output, reflexes) -Stock out of urine dipstick -Inaccurate measurement BP &/or failure to monitor vital signs per protocol before & after delivery -Failure to diagnose severe PE/E promptly -Failure to refer or to treat/ deliver per protocol -Stock out urine dipstick, MgSO4 -MgSO4 for severe PE or E -Delivery within X hours of diagnosis for severe PE/E (per protocol-to be defined) -Steroids to promote fetal lung maturity if < 34 weeks -Routine monitoring for MgSO4 toxicity (urine output, respirations, reflexes) -Continued monitoring after delivery -Routine monitoring BP in labor and post-partum -Routine urine protein screening if DBP > 90 -Definitive management severe PE/E: MgSO4 & delivery w/in X hours per protocol or Referral with loading dose MgSO4 Clinic with Maternity -Inaccurate measurement BP &/or failure to monitor vital signs per protocol before & after delivery -Stock out urine dipstick/broken BP measure gages -Routine monitoring BP in labor and post-partum -Routine urine protein screening if elevated BP -Referral for consultation for mild PE -Failure to recognize & refer for elevated BP +/- urine -Urgent referral w/loading dose MgSO4 for severe PE/E protein -Transport not available -Weak counter-referral to support ambulatory mgmt mild PE Mobile Spot, Health Post or Clinic without maternity (ANC + PNC only) Same as for clinic with maternity -ANC: Systematic Screening BP & Urine protein every visit -ANC/PNC: -Referral for any DBP > 90 (with or without urine protein) -PE danger sign detection & counseling science help achieve the MDG targets? 11

12 Portfolio of Activities to Achieve Strategic Goals: Systemic Issues Workload/ perceived workload at referral hospitals Staffing of MNH services, in particular specialists Provider competence, motivation Equipment, Maintenance of Equipment, Supplies & Drugs Referral/ counter-referral between levels of care Deploying Resources to Achieve Strategic Goals: Facilities Catering for Mothers and Newborns At the national level: Under the DHMT s: National Referral District Hospitals x7 Hospitals x2 Primary Hospitals x16 Private Hospitals x2 Clinics x279 Private Clinics With Maternities Military Services x111 Missionary Hospitals x2 Only ANC & PNC Mining Hospitals x3 x168 Health Posts x351 Mobile Stops x876 science help achieve the MDG targets? 12

13 Deploying Resources to Achieve Strategic Goals National level resources Strategic: Advocacy Committee Executive: Reference Group National to District Field Operations Team report to Clinical Services District Level Resources Leader: Manager, DHMT Focal Person: tbd (midwife) District to Facility Field Operations Team Facility Level Resources Providers of care Deploying Resources to Achieve Strategic Goals: National Level Resources: National to District Field Operations Team Creates link between national and district structures Roles: Transfer national directions to districts Transfer data and information from district to national level Transfers learning across all districts Membership: Approx. 10: each combining two focus areas: MNH & QI Each supports approx 3 DHMT s or facilities not under DHMT s Where do they come from: Use existing staff of SRH x3 Re-assign MOH staff (EMOC x10) Explore recruitment of project posts Explore development partners science help achieve the MDG targets? 13

14 Deploying Resources to Achieve Strategic Goals: National Level Resources: District to Facility Field Operations Teams in Each District Creates link between districts and their facilities Roles: Transfer national directions from districts to facilities Transfer data and information from facilities to districts Transfers learning across all facilities Membership: Number depends on facilities in district - in pairs combining two focus areas: MNH & QI. Approx 3 facilities per pair Where do they come from: Re-assign DHMT staff (esp. MNH & QI) Re-assign facility staff UN High-Level Panel on Post 2015 Agenda Appointed by the UN Secretary General Consulted: 5000 civil society organizations in120 countries in every region 250 companies in 30 countries, with annual revenues exceeding $8 trillion Thematic, regional, and country consultations all over the world Survey results from over half a million individuals on priorities for the future The Panel has recommended five transformative shifts and 12 illustrative goals. If the 12 goals are all carried out, the five transformative shifts would be achieved UN Member States are currently in the process of developing the agenda Source: United Nations science help achieve the MDG targets? 14

15 UN High Level Panel: Five Transformative Shifts 1. Leave No One Behind 2. Put Sustainable Development at the Core 3. Transform Economies for Jobs and Inclusive Growth 4. Build Peace and Effective, Open and Accountable Institutions for all. 5. Forge a New Global Partnership Source: United Nations The 12 Illustrative Goals 1. End Poverty 2. Empower Girls and Women and Achieve Gender Equality 3. Provide Quality Education and Lifelong Learning 4. Ensure Healthy Lives 5. Ensure Food Security and Good Nutrition 6. Achieve Universal Access to Water and Sanitation 7. Secure Sustainable Energy 8. Create Jobs, Sustainable Livelihoods and Equitable Growth 9. Manage Natural Resource Assets Sustainably 10. Ensure Good Governance and Effective Institutions 11. Ensure Stable and Peaceful Societies 12. Create a global enabling environment and catalyze long-term finance Source: United Nations 30 science help achieve the MDG targets? 15

16 Potential Impact by 2030 By 2030 the world would have: 1.2 billion fewer people hungry and in extreme poverty 100 million more children who would otherwise have died before they were five 4.4 million more women who would otherwise have died during pregnancy or childbirth 1.3 billion tons of food per year saved from going to waste 470 million more workers with good jobs and livelihoods 200 million more young people employed with the skills they need to get good work 1.2 billion more people connected to electricity 190 to 240 million hectares more of forest cover $30 trillion spent by governments worldwide transparently accounted for Average global temperatures on a path to stabilize at less than 2 C above preindustrial levels 220 million fewer people who suffer crippling effects of natural disasters Source: United Nations Sustainable Development Goals (SDGs) Rio 20+ Held in Brazil June nd, 2012 Agreed that the two processes (MDG and sustainable development goals) should be closely linked An open working group(30 member nation) was mandated by the Rio+20 to prepare a proposal on SDGs for consideration by the Assembly at its 68th session Source: United Nations science help achieve the MDG targets? 16