Using the Standard Based Management and Recognition Approach to Improve the Quality of Care and Malaria Control in Pregnancy in Akwa Ibom State Emmanuel Otolorin, William R Brieger, Bright Orji, Joseph g g j p Okeibunor, Gbenga Ishola and Barbara Rawlins
Akwa Ibom State, Nigeria: Year Round Malaria Risk Map of Nigeria Showing the Six (6) Geo-Political Zones Sokoto Niger Chad Kebbi Zamfara Katsina Kano Jigawa Yobe Borno Bauchi Kaduna Gombe Niger Be enin Oyo Ogun Lagos Kwara Osun Atlantic Ocean Ekiti Plateau FCT, Abuja Nassarawa Kogi Benue Ondo Edo Enugu Anambra Ebonyi Delta Cross River Imo Abia BayelsaRiversAkwa Ibom Taraba Adamawa Cameroun Zone Southsouth Southeast Northcentral t Southwest Northeast Northwest CDI MP PILOT 2 2
3 Background Jhpiego with support from ExxonMobil Foundation and the Akwa Ibom State MOH is working to reduce burden of malaria in pregnancy (MIP) using a two-ponged approach to reach pregnant women improving the quality of antenatal care (ANC) services and community involvement through communitydirected intervention (CDI) 3
4 of 1280 Respo ondents Percent 60 50 40 30 20 10 0 Baseline in 2007 - MIP Indicators during Last Pregnancy 60% was RBM Target for 2005 11.6 58 5.8 23.33 11.7 13.8 Any IPTp IPT2 or Slept under Slept under Slept under more ITN ITN every ITN Last sometime night Night (All Local Governments) 4
Nigeria MIP Partnership Concept and Project Design CLINIC MIP performance standards developed and implemented Training, Supervision i Mobilization, Commodities Referrals, Records, Feedback COMMUNITY MIP skills and responsibilities implemented through community directed intervention 5 5
6 IPTp and ITN Delivery in the Community 6
Improving Quality of Care in the Clinic Setting 7
Quality Improvement Processes: Standards Based Management and Recognition SBM-R is a collaborative process Assessments are both external and internal assessments Assessments lead to action plans Plan implementation leads to measurable progress 8 8
SBM-R Scores (%) for All EmONC Services Follow-up Assessment: Overall Performance Scores Percen tage 70 60 50 40 30 20 10 0 4.6 33.8 54.5 55.9 61.3 Baseline -2008 1st -2008 2nd - Apr 2009 3rd Aug 2009 4th Dec 2009 Number of time and period of assessment Number of EmONC Performance Standards = 173 9
SBM-R Scores (%) for ANC Services FANC thematic ti Area Perce ntage 100 80 60 40 20 0 12.9 57.2 84.1 82.5 86.7 ve staff f er Massiv transfe Baseline - 2008 1st -2008 2nd - Apr 2009 3rd - Aug 2009 4th - Dec 2009 Number of time and period of assesment e Number of ANC Performance Standards = 16 10
Persistent Gaps (FANC) Persistent stock-outs of antimalarial drugs in all the heath facilities. Health workers prescribe ACT but not sure if pregnant women do procure and use standards 13, 14 affected Health workers frustrated and give SP or CQ for malaria treatment standards 13, 14 affected Lack of RDTs and supplies to perform malaria parasite tests Some of the facilities have toilets but no water to make them functional standard 5 of Human, physical and maternal resources area affected Facilities lack culturally appropriate posters and IEC materials on EmONC with particular reference to MIP standard 8 of IEC area affected 11
12 IPTp Took SP Twice Last Pregnancy IPTp with SP was provided in the intervention arm at both ANC Clinics and through volunteer Community Directed Distributors. In the control area SP was made available at the clinics. 12
13 Used ITN During Last Pregnancy ITN supplies were difficult to obtain. The World Bank Booster support for Akwa Ibom State was delayed and not available throughout the intervention period. 13
14 Conclusions Quality of MIP control improved with use of the SBM-R process though massive transfer of health staff trained by the project later slowed quality gains Receipt of two doses of IPTp was significantly more in the study intervention clinics Use of ITNs was higher in intervention clinics though irregular stocks of commodities made ITN distribution difficult Continued charging of user fees by local governments discouraged ANC attendance 14
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