Engaging Users for Quality Enhancement and Rights (EU QUERO):Strengthening the maternal and child healthcare system over the first 1000 days in Brazil

在巴西，尽管有改善政策，但妇女和儿童在生命最初1000天（从受孕到大约2岁）内可获得的医疗保健质量差异很大。这导致产妇死亡率和发病率高于巴西等国家的预期。这个名为EU QUERO（在葡萄牙语中意为“我想要”）的项目正在测试一项改善护理质量的干预措施是否可行，并表明它是否有可能成功。这将在巴西的Goiás和maranh<e:1>两个州进行，这两个州的孕产妇健康状况都比预期的差。在干预之前，将使用已经收集的两个数据集对当前质量进行一段时间的评估。这一分析的结果将使用最新的技术绘制地图，以便确定优质或劣质医疗保健的热点。这将通知选择干预的区域。欧盟QUERO干预措施在基本卫生单位（卫生系统组织的最小级别）内实施，包括两个不同的要素。第一个目标是使母亲和更广泛的社区更加了解她们在生命最初1000天内的不同阶段——怀孕期间、分娩期间、分娩后不久以及儿童健康方面目前可获得的护理质量。这将通过制定设施级质量记分卡来实现，这些记分卡将向用户突出医疗保健的好坏方面。记分卡将列出1000天内的四个不同阶段，并对每个阶段中母亲可获得的服务进行评级，其中质量最好的服务获得“钻石”评级，而最差的服务将获得“青铜”评级。以前的研究表明，通过提高卫生系统的透明度，了解这些方面可以提高质量，同时卫生工作者也了解他们没有发挥作用的方面，并作出协调一致的努力加以改进。干预的第二个要素是通过向母亲提供基于权利的教育。这将包括关于个人保健权利的知识，包括强调个人应享有的权利和预期的质量。这被视为赋予母亲权力，然后鼓励她们要求更多的保健提供者，再次提高护理质量。欧盟人权组织将编制这些记分卡和基于权利的教育材料，在选定的基本保健单位内传播，并在这种情况发生后，评估这是否是一种可行的干预措施，以便在更大范围内开展。质量改进将通过开发新的质量记分卡进行评估，记分卡将显示改进的内容，以及在研究的1000天期间是否有任何改进均匀发生。还将通过观察健康结果来评估质量，例如母亲是否得到充分的产前护理或儿童是否及时接种疫苗。另一个方面是明确注重确保在整个干预和评估过程中听到青少年的声音。该项目是与国家卫生部合作开展的，因此，干预措施的成功实施将为今后改善母亲和儿童保健的战略提供信息。它还将使母亲、社区、卫生工作者和政策制定者在整个实施期间参与进来，并由项目小组和这些利益攸关方共同制定实际干预措施，因此向母亲提供的材料既相关又可理解。将评估干预措施在巴西和其他国家的可扩展性，促进母亲要求获得最优质的护理，加强卫生系统，以满足这些需求。

The quality of healthcare available to women and children within the first 1000 days of life (from conception until about 2 years of age) in Brazil is highly variable, despite policies for improvement. This has led to higher maternal mortality and morbidity than may be expected in a country such as Brazil. This project, EU QUERO (meaning 'I want' in Portuguese), is testing whether an intervention to improve the quality of care is feasible to conduct as well as indicating whether it is likely to be successful. This will be conducted in two states of Brazil, Goiás and Maranhão, both of which have poorer maternal health than expected. Prior to the intervention, a period of assessment of current quality will be conducted using two datasets that have already been collected. Results from this analysis will be mapped using the latest techniques so that hotspots of good or bad quality healthcare can be identified. This will inform the areas selected for the intervention. The EU QUERO intervention is implemented within Basic Health Units (the smallest level of the health system organisation) and encompasses two different elements. The first is to make mothers and the wider community more aware of the current quality of care available to them at different points within the first 1000 days of life - during pregnancy, during delivery, in the immediate post-delivery period and with regard to the child's health. This will be conducted by the development of facility level quality scorecards which will highlight the good and poor aspects of healthcare to users. The scorecards will list the four different phases within the 1000 days and rate the services available to the mother within each phases, with the best quality services receiving a 'Diamond' rating, while the poorest will receive a 'Bronze' rating. Previous research indicates that knowledge of these aspects improves quality through greater transparency of the health system, while health workers also understand the aspects where they are not performing and make a concerted effort to improve. The second element of the intervention is through the delivery of rights-based education to mothers. This will include knowledge about individual rights to health care, including highlighting what an individual should be entitled to and the quality that should be expected. This has been seen to empower mothers who will then be encouraged to demand more of the health providers, again improving quality of care. EU QUERO will develop these scorecards and rights based education materials to disseminate within selected Basic Health Units and, following this happening, assess if this is a feasible intervention to conduct at a wider scale. Improvements in quality will be assessed through the development of new quality scorecards, which will indicate what has been improved and whether any improvements have occurred evenly over the 1000 days period under study. Quality will also be assessed through looking at health outcomes, such as whether mothers received adequate antenatal care or whether the child received vaccinations in a timely fashion. A further aspect is an explicit focus on ensuring that adolescent voices are heard throughout the intervention and evaluation. The project is conducted in collaboration with the state Ministries of Health and hence the successful implementation of the intervention will inform future strategies to improve healthcare for mothers and children. It will also engage mothers, communities, health workers and policymakers throughout the period of implementation, with the actual intervention co-created between the project team and these stakeholders, so the material presented to mothers is relevant and understandable. The intervention will be assessed for scalability within Brazil and in other countries, with mothers facilitated to demand the best quality care available, strengthening the health system as it responds to these demands.