Sustainability Assessment of a District-Wide Quality Improvement on Newborn Care Program in Rural Rwanda: A Mixed-Method Study

Abstract

Background: Neonatal mortality continues to be a global challenge, particularly in low-and middle-income countries. There is growing work to reduce mortality through improving quality of systems and care, but less is known about sustainability of improvements in the setting post initial implementation. We conducted a 12-month sustainability assessment of All Babies Count (ABC), a district-wide quality improvement project including mentoring and improvement collaborative designed to improve quality and reduce neonatal mortality in two districts in rural Rwanda. Methods:We measured changes in key neonatal process, coverage, and outcome indicators between the completion of ABC implementation and 12 months after the comple tion. In addition, we conducted 4 focus group discussions and 15 individual in-depth interviews with health providers and facility and district leaders to understand factors that influenced sustainability of improvements. We used an inductive, content analytic approach to derive six themes related to the ABC sustainability to explain quantitative results.Findings: Twelve months after the completion of ABC implementation, we found continued improvements in core quality, coverage, and neonatal outcomes. During ABC, the percentage of women with 4 antenatal visits increased from 12% to 30% and remained stable 12 months post-ABC (30%, p = 0.7) with an increase in facilitybased delivery from 92.6% at the end of ABC to 95.8% (p = 0.01) at 12-month post-ABC. During ABC intervention, the 2 districts decreased neonatal mortality from 30.1 to 19.4 deaths per 1,000 live births with maintenance of the lower mortality 12 months post-ABC (19.4 deaths per 1,000 live births, p = 0.7). Leadership buy-in and development of self-reliance encouraging internally generated solutions emerged as key factors to sustain improvements while staff turnover, famine, influx of refugees, and unintended consequences of new national newborn care policies threatened sustainability.

‘The objective was about not blaming one another’: a qualitative study to explore how collaboration is experienced within quality improvement collaboratives in Ethiopia

“…High levels of staff turnover were problematic for collaboration, this may be a particular issue where those trained in QI or who have the highest QI capacities are the most likely to be promoted elsewhere [ 35 , 36 ]. For QI to be sustainable some level of stability in the team is needed [ 37 , 38 ], unless QIC becomes institutionalized and known by all staff.…”

Quality Improvement in Public-Private Partnerships in Low- and Middle-Income Countries: A Systematic Review

“…Many of the authors discussed the challenges they faced and the resilience that was needed to overcome organizational, cultural, and resource constraints. Barriers to effective QI programs are common in virtually all settings, but especially in LMICs (27) given limited resources (12,13,37,43,54,56,64,76,83,94,95,121), competing priorities (49,93), natural disasters (90), ambiguous governance (12,13), political and social strife (40,42,44,67,74,76,104). A common challenge was a high turnover of nurses, healthcare staff, and QI team members, which made ongoing leadership directions and sustained changes di cult (28, 34,43,45,49,51,53,80,93,121,124) and led to loss of organizational memory and trust (15).…”

Iterative delivery of an implementation support package to increase and sustain the routine provision of antenatal care addressing alcohol consumption during pregnancy: study protocol for a stepped-wedge cluster trial

“…Such studies have found maintenance of workforce skills through ongoing training and mentoring opportunities, leadership buy-in and reviews of progress against improvement goals have sustained improvements in a range of antenatal care practices for periods between 1 and 5 years. 41 42 …”

“…This suggests that factors that commonly impede sustainment of care delivery change may not have been sufficiently addressed by the trial implementation support package39 and that specific sustainability strategies may be required to ensure achieved effect sizes are maintained 40. A limited number of studies have tested the effect of sustainability strategies in maintaining improvements in evidence-based interventions in maternity service settings,41 42 with none specific to alcohol care. Such studies have found maintenance of workforce skills through ongoing training and mentoring opportunities, leadership buy-in and reviews of progress against improvement goals have sustained improvements in a range of antenatal care practices for periods between 1 and 5 years 41 42…”

“…A limited number of studies have tested the effect of sustainability strategies in maintaining improvements in evidence-based interventions in maternity service settings,41 42 with none specific to alcohol care. Such studies have found maintenance of workforce skills through ongoing training and mentoring opportunities, leadership buy-in and reviews of progress against improvement goals have sustained improvements in a range of antenatal care practices for periods between 1 and 5 years 41 42…”