The MNH QoC network initiative

Implementation progresses & results

Health service Quality Directorate

May 2021
 Outline
Introduction
Implementation arrangement and progress
Major results
Lessons
Conclusion
 Introduction
Substantial decline in maternal and Improved maternal health
under five mortality outcomes in coverage
the last subsequent years.
74% of women received
Proportion of deaths occurs during antenatal care from a
the neonatal period were reduced
skilled provider,
at a slower rate
43% received four or more
High burden of Neonatal and
Maternal deaths. ANC visits and
Neonatal morality 29 per 1000
48% of women delivered in
births, MMR of 412 per 100,000 a health facility.
births , (2016 EDHS)
improvement in maternal health coverage needs to integrate health care quality to address the current persistent
disparities and unmet need for maternal health care
Implementation paths..
 Introduction
The first Ethiopian National health
care quality strategy (2016-2020)
was launched and MNCH quality
of care identified as one the five
national health care quality
priority focus area.

These created an opportunity for Ethiopia to join the WHO led Global network to ‘Improve Quality of Care for
Mothers, Newborns and Children.
The Network provides a platform for countries to ensure that quality of care becomes an integral part of health care
delivery; it facilitates inter-country learning, knowledge sharing, and generation of local evidence and best
practices.
 The MNH QoC Roadmap

situational analysis conducted using the

WHO MNH QOC analysis framework c
Goal
reducing institutional maternal and
newborn deaths and stillbirths by
50% by 2020 and
Achieving a measurable
improvement in user satisfaction
with the care received
 Strategic objectives
Leadership: Build and
strengthen national institutions
and mechanisms for improving
quality of care in the health
sector.
Action: Accelerate and sustain
implementation of quality of care
improvements for mothers and
newborns.
Learning: Facilitate learning,
share knowledge and generate
evidence on quality of care.
Accountability: Develop,
strengthen and sustain
institutions and mechanisms for
accountability.
Implementation arrangement and progress
 Where and when?
The HSQD in collaboration of development partners established district based
learning collaborative network.
Targeted 14 districts representing the agrarian, pastoralist and urban set ups (3
- 5 learning health facilities per district ) in 8 regions and 1 city admin.
Lead Hospital and/or Primary Hospital & 2-3 Health centers
A total of 48 learning health facilities (8 referral & general hospitals, 12 primary
hospitals, and 28 health centers.)

Implemented since July 2018 (first months of 2011 EFY- July 2012)

2010 EFY considered as baseline year (Pre-implementation)

2011 EFY – 2013 EFY implementation year (Follow up years)
 Leadership
At National Level
A Health service quality directorate (HSQD) with the objective of setting the quality
agenda across Quality Planning, Quality Control and QI – and to drive it forward at the
national level (QI case team and SaLT case team)
A steering committee established in order to accelerate the
achievement of system-wide transformational change in quality
Technical Working Groups (TWG): Health Care quality, MNH QED and
Patient safety.
Maternal and newborn quality of care network in the 14 districts become one
of the flagship large scale QI initiatives, (Annual costed work plan aligned
with RHBs and budget support for RHBs, Districts and HFs)

Engaged key technical partners, define roles, commitments and

responsibilities to support the implementation

Advocacy MNH qoc using official MOH

website u,sh
 Leadership
RHB Quality units established with current staffing ranging from
three to six.
The quality unit at regional level supported by the RNB Technical Working
Groups (TWG)
Zone/sub-city. A quality case team established in most of them with two
to four staff members
Woreda(District). one to two focal persons assigned for quality
One MNH QED focal in all the 14 districts
Public Hospital. A quality and clinical governance unit headed by a General
Practitioner (GP) and with two to six staff, depending on hospital capacity and Region.
Public Health Center. A quality committee with a focal person assigned from team
members. Performance Monitoring Team (PMT) and a QIT that works to improve quality
and performance
Community. Multiple activities have been performed to engage the community through
the town hall meetings and implementation of community scorecard
 Action
MNCH quality standards were developed based on the WHO standards included as
one chapter in the Ethiopian Health sector transformation for quality guideline
(HSTQ)
Established district based learning collaborative network and provided support on
the implementation the MNH QoC roadmap packages.
Basic and advance QI trainings
The National QI coaching guide was also developed and introduced in the MNH QoC
learning sites
2 rounds of QI coaching training provided to the established pool of QI coaches from
Districts and lead Hospitals
In collaboration with supporting partners. (Transform PHC, Transform HDR, IHI, CHAI
& WHO) on-site mentoring and coaching support provided to build clinical and QI
skills of learning health facilities. (Annual from MOH level, 2 months-quarterly basis
from District based teams)
Maternal and Perinatal death surveillance and response system (MPDSR)
strengthening (Trainings, tracking and feedback on maternal deaths)
 Learning
WHO MNH QoC Monitoring and Evaluation framework were also adopted and
implemented to track implementation of the program and results that includes
fifteen common core indicators measuring provision of care, experience of care
and WaSH.
Additional Process and outcome measures from DHIS2/HMIS, and from
HPMI/Hospital KPI to inform QI opportunities and track improvement at all levels
Use of MPDSR data to inform QI efforts in the learning health facilities
DHIS2 and data quality trainings including orientation on MNH QoC CCI measutres
Integrating key MNH Quality measures in to routine HMIS systems underway
Bi-annual National MNH QoC learning collaborative
Annual Quality summit (MNH QoC as one of the priority and 14 districts actively
participating)
MNH QI work reflected in Annual Health care quality bulletins
Support the design and implementation of QI projects, documentation and sharing
of best practices and lesson learnt across the learning network
Accountability
MNH QoC measures including Maternal and newborn
outcomes & patient experience as Key performance
measures tracking and feedback provision,
Strengthening MPDSR system implementation
Major results
 Major result
Three outcomes measures included in the MNH common core
indicators reporting system which have been collected and
reported by the 48 learning health facilities were used to
assess the achievement of the network intended outcomes
Institutional pre-discharge maternal mortality,
Institutional pre discharge neonatal deaths and
stillbirth.
2nd year (2012 EFY)and 1st year (2011 EFY) results compared
against the pre- implementation period or baseline year status
(2010 EFY).
 Pre Discharge Maternal Mortality
Measure
All HFs MMR per Quarter
: Run Chart
Decline in 200 174
114
pre- 150 121
133
122
132

discharge
108 114
106
91 91 96
100 81

maternal
65

MMR
48 Median
50
mortality per 0
100,000

2010 Q1

2010 Q2

2010 Q3

2010 Q4

2011 Q1

2011 Q2

2011 Q3

2011 Q4

2012 Q1

2012 Q2

2012 Q3

2012 Q4

2013 Q1

2013 Q2

2013 Q3
births
compared to Time
the baseline
period
MMR by HF type, Baseline, Year 1,year 2
(Highest
decline for 180
159 154
PH) 160
140 120 128 127
120 109
100 95
82 86
80 9% 21% 3% 20%
60 36% 32%

40
20 9
0 0
0
All Health facilities Referal & General Hos Primary Hos HCs

Baseline 2011 EFY 2012 EFY

 Pre Discharge Neonatal Mortality
Measure
Run Chart
Decline in 25

Pre 20

discharge 15
neonatal

NMR
10
mortality Median

more than 5

20% in year 0

2010 Q1

2010 Q2

2010 Q3

2010 Q4

2011 Q1

2011 Q2

2011 Q3

2011 Q4

2012 Q1

2012 Q2

2012 Q3

2012 Q4

2013 Q1

2013 Q2

2013 Q3
2 (For all Hfs
aggregate
Time
and by HF
types ) 35.0
30.8
30.0 28.0
In year 1 the 25.0 23.4
decline is 7- 20.4
18.9
20.0
9% except 16.4
primary 15.0
Hospitals 11.0 9.9 11.0
10.0
with no
change 5.0 7% 20% 9% 24% 9% 0% 5% 80%
1.5 1.4 0.3
0.0
All Health facilities Referal & General Hos Primary Hos HCs

Baseline 2011 EFY 2012 EFY

 Still birth rate
SBR for all HFs Measure Fresh Strillbirths: Measure
Still Births Rate: Run Chart Median
aggregated 25
Run Chart 35
Measure Me
progress for Maserated Stillbirths: dian
30 Run Chart
year 1 showed 20 16
slight reduction 25 14
15
while showed 20
12
increment for 10 10
year 2 15
8
5 10 6

0 5
4
fresh stillbirth
201
201
201
201
201
201
201
201
201
201
201
201
201
201
201
2
declined by 0
0

2010 Q1

2010 Q2

2010 Q3

2010 Q4

2011 Q1

2011 Q2

2011 Q3

2011 Q4

2012 Q1

2012 Q2

2012 Q3

2012 Q4

2013 Q1

2013 Q2

2013 Q3
6.1% for 2011

201
201
201
201
201
201
201
201
201
201
201
201
201
201
201
and 22.6% for
2012 and
reversed for
macerated 35.0 32.7 32.0
stillbirth 30.1 29.6
30.0
26.6 25.6
25.3 24.2 24.7
25.0
Primary
Hospitals 20.0
showed declined
SBR for both 15.0
years (20% for 8.7
10.0
2011 and 23%
7% 20% 9% 24% 9% 0% 5.4
5% 5.2 80%
for 2012) 5.0 5% 2% 9% 20% 23%
4%
Macerated SBR 0.0 3% 63%
increased for All Health facilities Referal & General Hos Primary Hos HCs
both years
(7.3% & 80%) Baseline 2011 EFY 2012 EFY
 Lesson learnt
Building Leadership capacity and mechanisms for quality of care is vital
for improved health care outcome.

Building and strengthening district based coaching support in existing

administration structures ensure sufficient expertise availability and help
to sustain quality improvement

Strengthening data system and feedbacks and using indicators tracking

key prioritized improvement factors cornerstone for improvement.

Linking quality improvement with Maternal and perinatal death

surveillance is crucial for improving maternal and perinatal quality of care
outcomes.
 Conclusion
Though the performance across the health facilities may be affected by the variation
in the existing resource availability such as medical supplies, human resource and
other structures, the early results of the MNH QoC network implementation has
shown promising result with respect to reduction in institutional mortality outcomes

Efforts for Improvement in quality of care guided by defined system wide approach
strategy and improved stakeholder coordination and partnership.

continued and sustained implementation of the quality improvement efforts may also
be required for long term and sustained results.
Thank you!