Why It Matters
“[Local teams] are doing a lot with [limited] resources. We need to go there open to learning from them and willing to adapt how we work.”
Starting in 2019, an Institute for Healthcare (IHI) project called Alcançar (translated as “to reach” in English) embarked on a groundbreaking mission to reduce maternal and neonatal mortality rates in Nampula, Mozambique. A multi-partner strategy financed by the US Agency for International Development (USAID) and led by FHI 360 with quality improvement (QI) leadership from IHI, the project aimed not only to reduce maternal and newborn mortality but also to establish Nampula Province as a model health system for maternal, neonatal and child health services for other regions. By building the QI capability and capacity of local health workers and using a system of collaborative learning, Alcançar saw a 62 percent reduction in maternal mortality from 128 per 100,000 live births in the baseline period (May through October 2019) to 47 per 100,000 live births from September 2020 through May 2022. Additionally, the project achieved these results despite the added challenge of the COVID-19 pandemic.
In recent interviews, Shamir Carimo, MD, Alcançar's Provincial Quality Improvement Advisor, and Jacqueline Torres, PhD, RN, IHI Faculty and former Alcançar’s Technical Director, described the lessons that emerged from this project, highlighting the power of co-design, shared learning, and adaptability.
Leading with Humility, Building Capability and Capacity
Torres emphasized that it was important to avoid approaching the local improvement teams as if IHI knew all there was to know about the problems they were facing and how to solve them. She described the value of taking time to build relationships and trust, understand how local systems worked, and listen to those with context expertise. “We need to be humble, especially when we are working in a country classified as ‘developing,’” Torres advised. “[Local teams] are doing a lot with [limited] resources. We need to go there open to learning from them and willing to adapt how we work.”
Carimo agreed, describing how using QI tools empowered local health care providers to identify solutions suited to the specific obstacles they were facing. Now that the teams in Nampula know how to use tools like the fishbone diagram (also known as an Ishikawa or cause and effect diagram) “they are now able to find the gaps [in care], find the root causes of those gaps, and find some potential solutions for those gaps,” he noted. Developing improvement capability and capacity and introducing tools like the MEOWS (Modified Early Obstetric Warning Score) also helped the teams act with more assurance and make better-informed decisions. “They can manage obstetric complications efficiently,” Carimo explained. “We can see the establishment of a quality improvement culture.”
The Keys to Engagement
Closely partnering with local teams became another key to the success of Alcançar. “Co-design is the big lesson [of Alcançar],” Torres stated. “When we co-design, people feel they are involved. We gain their trust.” She emphasized the value of teams feeling respected and understanding that their full participation is necessary to see improvement. “We needed their ideas because we didn’t know what they know about maternity care and women and babies’ needs in their culture,” Torres said.
Trust also became essential to developing leadership engagement. As is often the case throughout the world, prior to Alcançar, data had typically been used for judgement and not improvement in the health care system in Nampula. Consequently, there was understandable uneasiness about data. Carimo recalled that Alcançar trainers explained that without numbers to track their progress, leaders could not make informed choices. “Little by little, step by step,” he recalled, “we helped them understand the importance of reporting data for decision making.” The turning point was when the leaders and their teams realized “the data is for them,” as Torres put it.
Collaboration and Resilience Amid the Pandemic
Unlike improvement efforts confined to one place or team, Alcançar used a collaborative model. Teams from different regions were brought together to share their experiences and ideas to foster a robust knowledge exchange. By breaking down silos and encouraging communication, the project achieved a more profound impact. According to Torres, “When you put different teams together, we gain a lot of knowledge. This is why we work in this model.”
As COVID-19 spread widely throughout the world in 2020, it presented unexpected challenges for Alcançar, especially for collaboration. With limited resources and sometimes unreliable internet access in rural areas, the project leveraged widely available digital tools for training, sharing case studies, and communication and adapted content to work on platforms with which the teams were already familiar. This strategy proved to be less expensive than meeting in person, allowing for widespread participation. Strategies, such as recorded sessions for asynchronous learning, enabled continued progress. The team's adaptability, creativity, and resourcefulness in the face of adversity were crucial to maintaining momentum.
Results and Impact
Five years into the project, the outcomes speak volumes. Teams have transformed their approach to care by incorporating QI tools and methods. The use of data has become integral to identifying areas for improvement. The application of evidence-based strategies led to a significant decrease in maternal and neonatal mortality rates in Nampula. Bundles and clinical packages of care for the prevention and management of postpartum hemorrhage, puerperal sepsis, and preeclampsia saw increased utilization.
“Teams are applying quality improvement tools and methods,” Torres reported. “They are testing ideas on a small scale. They are also collecting and using data related to process indicators.” Alcançar teams are using this data to identify where to focus their improvement efforts and identify the barriers they need leadership support to address.
Carimo, who grew up in Mozambique, expressed pride in being part of Alcançar and is hopeful about its lasting effects in his country. Torres expressed excitement over those trained using their QI skills in areas beyond maternal and neonatal care. She described, for example, a doctor who has applied the knowledge he learned from Alcançar to improve HIV programs in the province.
Lessons learned from the Alcançar project can be applied globally. By respecting and co-designing with the local workforce, Alcançar not only implemented successful strategies but also instigated a cultural shift in the use of data for improvement. Alcançar’s journey exemplifies the transformative power of collaboration, adaptability, and humility in overcoming challenges. Its success to date has been not only in reducing maternal and neonatal mortality rates but also in building sustainable QI practices that can empower local health care providers beyond this project.
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