Designing Projects for Equity

Transcription

1 Designing Projects for Equity Session C: 1:30 2:45pm Kathryn Brooks Amy Reid Abiyou Kiflie

2 Agenda 2 10 mins Welcome 15 mins Framing & Overview 30 mins Ethiopia Case Study 15 mins Discussion

3 Welcome 3

4 What is Health Equity? When all people have the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance. CDC

5 What is Health Equity? A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. Healthy People 2020

6 What is Health Equity? A difference or disparity in health outcomes that is systematic, avoidable, and unjust. CDC

7 The -Isms Prejudice + Power Norms, structures, policies, practices that advantage one group over another. Differential access to goods, services, and opportunity of society by race. People s institute for survival and beyond phyllis-jones, ajph

8 Equity & Quality Care 8 Equity is forgotten IOM aim In order to reach any of our aims fully, equity is needed We recognize that inequities are a product of our systems Improvement tools give us a way to make systems better, but not without intentionality Equity must be a priority and you must have infrastructure to support that priority What part of your culture helps and hinders equity?

9 Co-design for equity 9 Listen. What matters to our community? How are improvement projects selected? Get the data. Where are the gaps? But! don t let imperfect data slow you down Build a representative team. Whose voice is missing and why? Discuss power and equity in team processes Understand the history of your organization as it relates to your community

10 Key Improvement Design Elements 10 What are we trying to accomplish? Aims for equity What changes can we make that will result in improvement? Theory of change for equity How will we know a change is an improvement? Measurement for equity How do we engage our colleagues in change that advances equity? Organizing for equity

11 Improvement Aims 11 How much, by when, for whom, boundaries of system? Does aim explicitly intend to narrow gaps between groups and/or support a marginalized group? Decrease maternal mortality by 50% by May 2019 and narrow the gap between X and Y by 50% in Region ABC. By December 2018, at least 90% of patients agree or strongly agree they have had an excellent experience in our facility and the gap is narrowed by 50% between A and B patients.

12 Measurement 12 Assess your data capability and data quality to identify and track equity. Stratify your data by relevant sociodemographic factors. Do not wait for perfect data to start improvements aimed at narrowing equity gaps. Design dashboard with equity data as part of regularly tracked items so it is not a separate add-on.

13 Improvement Theory 13 Process of generating change ideas who are you getting these from? Missing voices? Driver diagram & change ideas Who do these work for? Who do we miss? Shift from individual/interpersonal to structural

14 How do we engage colleagues in change? 14 Challenges include fear, lack of buy-in and competing priorities Co-produce in authentic relationships Clarify the ask Tap in to motivations and values, co-design with those most impacted, meet people where they are, start small, Have courage to name issues

15 Lessons Learned 15 Common Pitfalls Individuals v systems Not sharing decision making power Not enough time to talk about team dynamics Not enough communication Tips From whom do you need buy in and support? Don t wait for perfect Ask who benefits and who is burdened in your design decisions Be on your own personal journey

16 Case Study: Ethiopian Health Care Quality Initiative

17 Ethiopia Country Background Total Population, 2017: 94,228,000 GDP per capita, 2017: US $660 Health expenditure, 2013/2014: 2.6 billion ETB (4.3% GDP) Neonatal Mortality, 2016: 29 per 1000 live births Maternal Mortality, 2016: 412 per 100,000 live births Facility delivery: 26% Sources: World Population Review, WHO, EDHS 2016

18 NMR / MMR Compared to other countries in Africa Rank Country NMR Central African Republic Cote d'ivoire Nigeria Sierra Leone Djibouti Sudan Ethiopia Niger Cameroon Zambia Kenya Tanzania Uganda Rwanda South Africa 12.4 Rank Country MMR Sierra Leone 1,360 4 Nigeria Cameroon Nigeria Kenya Tanzania Burkina Faso Togo Madagaskar Ethiopia Uganda Sudan Rwanda Zambia South Africa 138 Sources: CIA World Factbook 2015 UN Inter-agency Group for Child Mortality Estimation ( UNICEF, WHO, World Bank, UN DESA Population Division ) at childmortality.org.

19 Ethiopia NMR / MMR on Global Scale Rank Country NMR Pakistan Sierra Leone Ethiopia Kenya Iraq Egypt, Arab Rep Iran, Islamic Rep United Arab Emirates United States United Kingdom Greece Sweden Singapore Japan San Marino 0.6 Rank Country MMR Sierra Leone 1, Kenya Ethiopia South Africa Iraq Egypt Iran United States Singapore United Kingdom United Arab Emirates Japan Sweden Greece 3 Sources: CIA World Factbook 2015 UN Inter-agency Group for Child Mortality Estimation ( UNICEF, WHO, World Bank, UN DESA Population Division ) at childmortality.org.

20 Health Equity in Ethiopia Inequities exist among many sub-populations within Ethiopia for both service coverage and health outcomes: Regional: Maternal mortality: 743 and 717 per 1,000 live births in Somali and Afar regions, respectively, compared with 234/1,000 LB in Addis Ababa Urban/Rural: Skilled attendance at birth: 79% for urban population vs. 20% for rural (from DHS) Rates of ANC 1 visits 45.5% higher in urban settings than rural (add under 5 mortality, immunization coverage, diagnosis + treatment of common diseases) Wealth Quintile: Children from richest quintile 2.44 times more likely to receive pentavalent vaccine (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenza type b) compared to children in poorest quintile Sources: DHS 2016; State of Inequality in Ethiopia report

21 Health Equity in Ethiopia What are the root causes of these disparities? Majority of population lives in big 4 regions higher resource allocation + intervention activity Health system structure not designed for nomadic populations; need new strategies to provide care in pastoralist areas Education strongly associated with accessing HC services; also with income levels and urban/rural/pastoral archetypes FMOH strategies to address inequities: Inclusion of Equity as a pillar of quality in HSTP Establishment of a Special Supports directorate focused on pastoralist regions

22 Ethiopian Health Care System Ministry of Health Agencies Regional Health Bureaus Zonal Health Department Woreda Health Office

23 HEW and HDA Structure Over 38,000 Health Extension Workers (HEWs) trained and deployed throughout the country to educate and empower families to take control of their own health. Families are mobilized by a Health Development Army (HDA) to enhance community engagement 1:5 network structure: one HDA representative to five women Groups of five form clusters of six groups with an HDA leader (thirty women to one HDA leader).

24 Improvements in Maternal and Child Health Ambitious initiatives of the FMoH led to a two-thirds decrease in child mortality between 1990 and 2015, thus achieving Millennium Development Goal 4 Critical progress in access and coverage However, rates of neonatal and maternal mortality remain unacceptably high, and disparities persist among sub-populations Further progress will require more system-level change Across health system levels Across the MNH continuum of care Move beyond coverage high quality, patient-centered, equitable care

25 Ethiopia Health Care Quality Initiative 25

26 Program Design Guiding Questions Where are the gaps? Where can IHI help in closing those gaps? Who are the stakeholders and what are their priorities? Who is being left out of the current system? How will this work be sustained in the long term?

27 Program Components Creation of Ethiopian National Health Care Quality Strategy with the Ethiopian FMOH Activate a culture of continuous improvement at all levels of the healthcare system Launch and test large-scale results-focused collaboratives in maternal and neonatal health

28 Overall Project Driver Diagram Development and Implementation of Unified Quality Strategy Institutionalized Culture of Quality Government Ownership Improved Healthcare Outcomes and Improved Quality of Health Services All Other Drivers of Quality Services (WHO Building Blocks) QI Capability Building MNH-focused Collaboratives

29 Elements of design incorporated specifically to advance equity Geography: inclusion of pastoralist collaborative Integration of Compassionate and Respectful Care work stream Inclusion of HEWs (community health workers) in collaboratives to create link with communities and groups often left out of system

30 Learning Collaborative Design Identify focus area and core indicators Conduct Baseline Assessment Address gaps in clinical and QI skills and supplies (training and procurement of essential supplies) Learning Session 1 Action Period 1 Learning Session 2 Action Period 2 Learning Session 3 Action Period 3 Learning Session 4 Finalize change package, publicize & spread Intensive coaching to support teams to improve system and skills gaps (visits, phone calls, engagement of program and supervisory managers, data collation & interpretation) months

31 MNH Collaborative Learning Session

32 Phased Design Prototype: One collaborative in each of five regions (Amhara, Oromia, SNNP, Tigray, and Afar) to test the collaborative design and develop regional change packages of successful change ideas to catalyze MNH improvement. Test of Scale: Fully integrate the design into existing public system and structures and test to scalability of the approach in 19 additional woredas.

33 Prototype Phase (18 months) Key = Agrarian = Urban = Pastoral

34 Test-of-scale Phase (18 months) Key = Agrarian = Urban = Pastoral

35 Progress to Date: Learning Collaboratives Fogera Woreda, Amhara (pop. 264,512) Launched April 2017 IHI MNH Initiative Regions IHI MNH Initiative Regions Tanqua Abergele Woreda, Tigray (pop. 107,081) Launched August 2016 Limu Bilbilu/Bekoji Woreda, Oromia (pop. 237,820) Launched April 2016 Amibara, Afar (pop. 94,718) Launching January 2018 Duguna Fango Woreda, SNNPR (pop. 118,051) Launched October 2016 = Prototype Phase Woreda

36 Collaborative Aim 36 Reduce maternal and neonatal mortality across Ethiopia by 30% over a period of 5 years Equity lens: For whom?

37 Theory of Change Increased Health Seeking Behavior Optimize the ability of the HEW to educate the community Community Engagement for awareness creation and positive influence Use culturally acceptable strategies to improve dissemination and uptake of key health messages Create positive experiences through every health encounter Utilize the Health Development Army structure to reach the house hold Use schools as a dissemination mechanism Use multimedia for Health education activities Use each facility visit to educate/counsel mothers towards raising their health seeking behavior Improved experience at care Reduce maternal and neonatal facility-based mortality in participating sites by 30% over a period of 30 months Improved mechanisms to reach appropriate level of health care facility Improved quality of care at health institutions (safe, effective, patientcentered, timely, efficient, equitable) Improved referral network Improving transportation mechanisms (ambulance and others) for immediate response Maximizing the potential of nearby health facilities to avoid unnecessary referral Create a culture of QI and leadership Availability of skilled and respectful health personnel Improve the reliability of the supply chain management system to deliver essential commodities all the time Availability of national guidelines, clinical protocols and job aids Create structure (QI teams, committees, plan) to facilitate and execute work Improve data quality through DQA s Create a learning platform for collaboration and routine use of data for improvement Increase the skills of health professionals and health managers to use QI methods and tools Organize learning collaborative among health facilities serving the same geographic areas (full Woreda Coverage) Training in key MNH national protocols Onsite mentorship to maintain skills and address skills gaps Maximize efficiency of existing facility staff Professionals get regular updates on the management and prevention of key causes of mortality Address gaps in essential commodities as defined in baseline assessment Dissemination of existing protocols and support for local development when necessary Timely identification, prevention and management of life threatening conditions to mothers and newborns Fast tracking/triaging/follow-up mechanism Reliable implementation of labor and delivery bundle Reliable implementation of the "MNH" checklists/relevant guidelines Support for a care delivery system that ensures respectful care for patients Incorporation of compassionate and respectful care (CRC) change ideas and training in learning sessions Clean, safe, comfortable spaces for patients and staff

38 Theory of Change Increased Health Seeking Behavior Reduce maternal and neonatal facility-based mortality in participating sites by 30% over a period of 30 months Improved mechanisms to reach appropriate level of health care facility Improved quality of care at health institutions (safe, effective, patient-centered, timely, efficient, equitable)

39 Adaptable design 39 Review of collaborative design with RHB and partners with extensive experience in Afar region Additional emphasis on addressing 1 st and 2 nd delays through community engagement-linked change ideas and improving referral systems.

40 Successful change ideas 40 Increasing patient centeredness of care: Restructuring of pregnant women s conferences to be more participatory and responsive to their needs Incorporation of cultural elements into maternity waiting homes Strengthening referral systems Back-referrals Reducing financial barriers to referrals Community-level resource mobilization for local ambulances QI methods as advocacy tool Facilities using data to more strongly advocate for increased resource allocation from their Region or zonal leadership

41 Learning Collaborative Core Indicators Process ANC (coverage) ANC (quality) Delivery Management (coverage) Delivery Management (quality)* Delivery Management (quality)* Delivery Management (quality)* Delivery Management (quality-sick newborns) PNC (coverage) PNC (quality-sick newborns) PNC (qualitypreterm/lbw) Antenatal care coverage four visits Measure Percentage of pregnant women tested for syphilis during ANC1 Proportion of births attended by skilled health personnel Proportion of deliveries with 100% compliance to on admission bundle Proportion of deliveries with 100% compliance to before pushing bundle Proportion of deliveries with 100% compliance to soon after birth bundle Proportion of neonates treated for birth asphyxia Percentage of women who attended postnatal care 48 hrs after delivery Proportion of neonates treated for sepsis Percentage of preterm or low birth weight infants put on KMC Data Source* HMIS HMIS HMIS Chart review with checklist Chart review with checklist Chart review with checklist HMIS or Delivery register HMIS HMIS or Delivery register Delivery register

42 Clinical Outcome/Impact Measures Institutional and community level (when available) measures of: Maternal Mortality Neonatal Mortality Stillbirths Perinatal Mortality

43 Measurement for Equity 43 Quantitative: Core collaborative indicators to be stratified by region and by geographic archetype (urban, agrarian, pastoralist) Qualitative: Assessment to better understand the mechanism of how QI leads to change, including effect on health worker motivation as it relates to quality of care Qualitative assessment of maternal perception of care and utilization of services

44 New frontiers/opportunities 44 3 opportunities identified through current work: 1. Increased quality of care at facilities opportunity to attract more women to facility care (pull factor for increased demand seeking) 2. Greater demand for facility services need to strengthen the newly pressured referral system 3. Empowering communities to participate in their health also provides the opportunity for greater patient involvement and direction of facility-based QI efforts to ensure that teams are prioritizing the right issues that matter most to people

45 New frontiers/opportunities 45 Hoping to expand focus on 1 st and 2 nd delays through additional community-focused activities. Study to explore demand creation Test new change ideas to address 1 st and 2 nd delays Participatory Women s Groups Testing additonal change ideas from collaboratives

46 Acknowledgements The Ethiopia Federal Ministry of Health Regional Health Bureaus, woreda and facility leadership, health care workers Bill and Melinda Gates Foundation Margaret A. Cargill Philanthropies

47 What is one next step you can take to advance equity in your improvement projects? 47