Guinea has extremely high maternal and child mortality and morbidity that was aggravated by the Ebola epidemic. The USAID Guinea USAID Guinea’s Health Service Delivery (HSD) activity implemented the Standards-based Management and Recognition (SBM-R) approach to improve performance, accessibility, and quality of facility-based health services in three primary domains including emergency obstetric and neonatal care, family planning, and infection prevention and control. Facilities in Guinea that participated in the SBM-R process were assessed on performance standards periodically through self-assessment and accreditation review. Facilities that achieved a minimum average score of 80% for correct implementation of the standards were accredited with a gold star.
As part of the performance evaluation of the Health Service Delivery activity, a realist case study explored the extent to which the SBM-R approach led to health service delivery improvements in the four years of the project and studied the potential for replication, scale-up, and sustainability.
SBM-R approach was implemented in the context of major structural challenges facing the health system, including chronic staff shortages and turnover, insufficient infrastructure, and community mistrust owing to the 2014-16 Ebola epidemic. The findings are categorized into – process and engagement, performance drivers including clinical performance, managerial performance, and equipment, supplies, and infrastructure.
Process and Engagement: The SBM-R process occurred in two steps – (1) a regular self-assessment carried out at the facility-level by a team of providers, senior managers, COSAH representatives, and community members. The second step involves the requests made by the facility to be externally evaluated by the national committee. The facility’s performance is based on the external review on a performance threshold and provided ‘star’ ratings. For instance, if the facility receives 80% or greater, it receives one star; a second star when the facility demonstrates performance for at least 86% of the standards. Of the 272 HSD-supported facilities, 97 implemented the SBM-R program, and about half of these facilities earned one or more stars. The 97 SBM-R facilities implemented the approach, on average, for four years. A wide variation was noted in the frequency of facilities’ level of engagement – 47% of all SMB-R facilities were considered to have low engagement with three or fewer assessments from 2017-2019.
Performance drivers: There were 3 performance drivers noted including clinical performance, managerial performance, and equipment and supplies.
Clinical Performance: The case study demonstrated marked improvements in scores for infection prevention and control practices with a wide range from a 25 to 70 percentage point increase. Other large improvements in clinical practice were attributed to obstetric interventions, though more improvements were needed for respectful care and complex health interventions. While family planning performance standards generally improved across the case study facilities, challenges in providing evidence-based information on specific family planning methods continued to be noted.
Managerial Performance: Several managerial issues were noted including poor client-provider communication; low availability of information, education, communication materials; lack of job descriptions for staff; and long wait times for clients.
Equipment, Supplies, and Infrastructure: Many of the facilities in the case study also faced challenges related to receiving supplies such as scales, blood pressure gauges, and examination tables. The facilities’ capacities to conduct sterilization and waste management were an issue due to a lack of disinfectants, antiseptics, and personal protective equipment. Overall, management was a critical player in alleviating these issues.
The research team used quantitative and qualitative data collection methods to evaluate the national, facility, and community levels covering a purposively chosen sample of 10 hospitals and 26 health centers. Data collection included key informant interviews, focus group discussions, observation checklists, and provider surveys; and secondary data included document review and quantitative facility-level data.
• Two key factors for performance improvement included: 1) HSD-provided inputs, such as training, equipment, and managerial guidance; and 2) facility-level receptivity to SBM-R.
• Training and equipment alone were insufficient to improve quality of facilities
• Leadership by facility managers and supervisors, coupled with the engagement and commitment of district and regional actors within the Ministry of Health, is essential.
• Long-term maintenance of facilities and equipment needs local management through participation from government officials, community leaders, and community members.
• Low engagement was a challenge across facilities despite a positive perception of SBM-R processes. This could be driven either by a sense of fatalism given the poor condition of the facilities or the perception of additional work needed to implement SBM-R.
The SMB-R processes were appreciated by staff and communities across locations, but higher-level leadership was noted as a key metric to drive participation in quality improvement processes more broadly. Facility improvements such as water, sanitation, and sterilization, and availability of basic equipment, were found to be necessary to improve staff morale and provide integrated quality care.