Stakeholder monitoring to improve quality of MNH care in public and private sector facilities following a district health systems approach

在孕产妇和新生儿健康(MNH)中强调提高护理质量，以提高干预措施的效力和效力。然而，既没有全球接受的定义，也没有任何标准化的工具来监测MNH的护理质量。孟加拉国正在按部就班地实现千年发展目标4和5的具体目标，机构执行率很低(29%)，其中大部分(18%)是在营利性私营部门设施中实现的。公共设施的护理质量差迫使孕妇使用私人设施，这可能导致灾难性的保健支出。由于激励机制，用户可能会认为来自私营部门设施的服务优于来自公共设施的服务。该国不受监管的私营部门增长迅速，有报道称，私人设施收费过高，并进行了不必要的剖腹产。双重做法在公共部门提供者中很常见，为了经济利益从公共部门转到私人部门并不少见。管理不力，无法监督多元化的卫生系统，私营部门在提供卫生保健方面的贡献越来越大。需要创新系统的办法，以便更好地整合私营部门的投入，以最大限度地为实现国家公共卫生目标作出贡献。审计和反馈已经证明了它在改善高收入国家临床环境中提供者业绩方面的可行性和有效性。哥伦比亚大学的Jhpiego(约翰霍普金斯大学国际妇产科教育计划)和AMDD(避免产妇死亡和残疾)等几个全球计划已经开发了工具来监测和提高MNH护理的质量。在这项研究中，我们计划审查现有的审计和质量改进工具，以使其适用于孟加拉国，以测试其可行性、可接受性和有效性，以按照地区卫生系统的方法提高MNH保健的质量。这项研究将在孟加拉国的一个表现中等的地区进行，采用混合的方法，即测试前-测试后的研究设计。所开发的工具将通过多个利益攸关方的协商确定背景，并在研究区域外的假设领域进行预测试后最终确定。将进行一项基线研究，以评估公立和私营医院的需求，并为今后的评估确定质量指标的基准。基线研究将包括SWOT和利益相关者分析，以了解背景并建立更广泛的联盟，以促进所设计干预措施的实施。将成立地区质量保证(QA)小组，由地区内的主要利益相关者组成，包括用户。已开发的监测和反馈工具将包括涵盖护理质量的结构、过程和结果方面的关键质量指标，并将通过地区质量保证小组成员每季度联合访问所有公共和私人设施来实施。每6个月通过研讨会和定期质量监测报告提供反馈。过程文件将是评估的关键方法。定性的关键信息者访谈探讨了影响卫生保健服务质量的实施和改变的有利和制约因素。量化的干预前和干预后调查将是评估由于引入利益攸关方的监测和反馈而导致的护理质量(包括技术和感知的)变化的其他方法。成本计算工作将衡量干预措施的成本，以便为扩大规模和可持续性的政策提供信息。研究结果将通过多种渠道传达给目标受众，如期刊文章、会议摘要、政策简报和报纸文章。将制定一项实施研究方案，为未来在全国范围内扩大影响孕产妇和新生儿健康结果的政策提供信息。

Improving the quality of care is emphasized in maternal and neonatal health (MNH) to enhance efficacy and effectiveness of interventions. However, there is neither any globally accepted definition, nor any standardized tool to monitor quality of care in MNH. Bangladesh is on-track in achieving the targets for Millennium Development Goal 4 & 5 with low institutional delivery rate (29%), the majority (18%) of which takes place in for-profit private sector facilities. Poor quality of care in public facilities compels pregnant women to use private facilities which may lead to catastrophic health expenditure. Users may perceive services from private sector facilities to be superior to services from public facilities due to incentive mechanism. The unregulated private sector is growing fast in the country and there are reports of overcharging and unnecessary caesarean sections in the private facilities. Dual practice is common among public sector providers and referral from public to private for financial benefit is not uncommon. Governance is weak to oversee the pluralistic health system where the private sector is increasingly contributing in the health care delivery. Innovative systems' approach needed for better integration of private sector inputs to maximize their contribution in achieving the national public health goals. Audit and feedback has demonstrated its feasibility and effectiveness in improving providers performances in clinical settings in high-income countries. Several global programs such as JHPIEGO (Johns Hopkins Program for International Education in Gynecology and Obstetrics) and AMDD (Averting Maternal Death and Disability) of the Columbia University have developed tools to monitor and improve quality of MNH care. In this study we plan to review the existing audit and quality improvement tools to adapt them in Bangladesh to test its feasibility, acceptability and effectiveness in improving quality of MNH care following a district health systems approach. The study will be conducted in a medium performing district of Bangladesh following a mixed method, pretest-post-test research design .The tools developed, will be contextualized through multiple stakeholders consultations and finalized after pretesting in a hypothetical field outside the study district. A baseline study will be conducted for needs assessment and benchmarking the quality indicators in public and private sector hospitals for future evaluations. Baseline study will include SWOT and Stakeholders Analysis to understand the context and building broader alliance to facilitate the implementation of the designed interventions. District Quality Assurance (QA) Team will be formed involving key stakeholders in the district, including the users. Developed monitoring and feedback tool will include key quality indicators covering structure, process and outcome dimensions of quality of care and will be implemented through joint quarterly visit of all public and private facilities by the district QA team members. Feedback will be given every 6 monthly through workshops and periodic quality monitoring reports. Process documentation will be the key method for evaluation. Qualitative Key Informants Interviews with explore the enabling and constraining factors impacting both implementation and making changes in quality of MNH care. The quantitative pre and post intervention surveys will be the other methods for assessing the change in quality of care (both technical and perceived) due to introduction of stakeholders' monitoring and feedback. A costing exercise will measure the cost of interventions to inform policy for scale-up and sustainability. Study outcome will be communicated to target audience using multiple channels such as journal articles, conference abstracts, policy briefs and newspaper articles. An implementation research protocol will be developed to inform policy for future scale-up nationwide to impact maternal and neonatal health outcomes.