The countdown for the Millennium Development …...International Forum 2014 9 April 2014 A1: Change...

International Forum 2014 9 April 2014

A1: Change on a global scale The countdown for the Millennium Development Goals: Can improvement science help achieve the MDG targets? 1

SESSION A1: CHANGE ON A GLOBAL SCALE

International Forum on Quality & Safety in HealthcarePalais des Congrès, Paris, April 8 – 11

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

SESSION A1: CHANGE ON A GLOBAL SCALE

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M. Rashad Massoud, MD, MPH, FACPDirector, USAID Applying Science to Strengthen and Improve Systems

Senior Vice President, Quality and Performance Institute

University Research Co., LLC – Center for Human Services, USA

Objectives

After this session, participants will be able to:

• Articulate the MDG goals and their importance 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

USAID Applying Science to Strengthen and Improve Systems

achieving the MDG target

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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


7. Ensure environmental sustainability

8. Develop a global partnership for development



Health MDGs 4, 5 and 6

USAID Applying Science to Strengthen and Improve SystemsSource: United Nations

Health MDGs Scorecard

GOALS AND TARGETS

Africa Asia

Oceania

Latin America

& the Caribbean

Caucasus & Central

AsiaNorthernSub-

SaharanEastern

South-Eastern

Southern Western

USAID Applying Science to Strengthen and Improve Systems6 Source: United Nations 2013



People living with HIV are surviving longer

USAID Applying Science to Strengthen and Improve SystemsSource: 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 ChanDirector General


Director GeneralWorld Health Organization

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McGlynn et al. NEJM 2003. “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

USAID Applying Science to Strengthen and Improve Systems9

Conclusion: The defect rate in the technical quality of American health care is approximately

45%

“… Between the health care we have and the

The Issue of Quality in Health Care

care we have and the care we can have lies not only a gap, but a chasm…”

“… The problems come from poor


psystems – not bad people…”



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 k l h l h ”


keeps people healthy ” —Jim Kim

President, World Bank

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USAID Health Care Improvement ProjectFY2014 Activities




USAID Applying Science to Strengthen and Improve Systems Project

FY2014 Activities


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

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, Uganda



Achieving System Level Results

Will

Build confidence

Newpossibilities


ExecutionIdeas

Sequencing and tempo

Execution

Achieve breakthrough

goalsg

Provide leaders forlarge system projects

Spread and sustain


Manage local improvement

Develop human resourcesProvide day-to-day

leaders for micro systems



Integrating Content and Organization of Care


Example: Maternal Mortality Initiative Botswana

• Goal: Reducing Maternal Mortality to Achieve MDG Target

• MDG Target: 81




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)



Portfolio of Activities to Achieve Strategic Goals: Overcoming Gaps in Clinical Care for Leading Maternal Complications

Leading Causes Maternal Mortality 2006-2010 (proportions vary by year)

• PPH

• Eclampsia

• Puerpal sepsis

• Abortion-related

• HIV-related

• Obstructed Labor


• Obstructed Labor

• Other (including respiratory, cardiac, protozoal, hepatitis, ectopic, embolism and other indirect causes)

Source: Health Statistics Reports, Botswana Central Statistics Office, www.cso.gov.bw/cso

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 InterventionsReferral HospitalMaternity

-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

-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

symptoms-Non-adherence with MgSO4 treatment guidelines-Failure to monitor for MgSo4 toxicity (respiratory, urine output, reflexes)-Stock out of urine dipstick

< 34 weeks-Routine monitoring for MgSO4 toxicity (urine output, respirations, reflexes)-Continued monitoring after delivery

Primary & District Hospital Maternity

-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

-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 BPReferral for consultation for mild PE


-Stock out urine dipstick/broken BP measure gages-Failure to recognize & refer for elevated BP +/- urine protein -Transport not available-Weak counter-referral to support ambulatory mgmt mild PE

-Referral for consultation for mild PE-Urgent referral w/loading dose MgSO4 for severe PE/E

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



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 &


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:

National Referral

• Under the DHMT’s:

District Hospitals x7– National Referral Hospitals x2

– Private Hospitals x2

– Private Clinics

– Military Services

– Missionary Hospitals x2

– District Hospitals x7

– Primary Hospitals x16

– Clinics x279

• With Maternities x111

• Only ANC & PNC


– Mining Hospitals x3 x168

– Health Posts x351

– Mobile Stops x876



Deploying Resources to Achieve Strategic Goals

• National level resources– Strategic:

• Advocacy Committee• Advocacy Committee

– Executive:

• Reference Group

• National to District Field Operations Team – report to Clinical Services

• District Level Resources• Leader: Manager, DHMT


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



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 region5000 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


g gcarried out, the five transformative shifts would be achieved

• UN Member States are currently in the process of developing the agenda

Source: United Nations



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


5. Forge a New Global Partnership


The 12 Illustrative Goals

1. End Poverty

2. Empower Girls and Women and Achieve Gender Equality

3 Provide Quality Education and Lifelong Learning3. 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


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

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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 five100 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


• 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 pre-industrial levels

• 220 million fewer people who suffer crippling effects of natural disasters


Sustainable Development Goals (SDGs) Rio 20+

• Held in Brazil June 20-22nd, 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


The countdown for the Millennium Development …...International Forum 2014 9 April 2014 A1: Change...

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