In life, the simplest solutions are often the best. When it comes to healthcare, they're also almost always the cheapest. It's striking then that we so often choose complex, costly, and ineffective healthcare solutions when more straightforward fixes exist.
This is part of why I founded ACCESS Health International, a leading think tank and advisory group with experts based around the world. We look at simple and successful solutions to improve access to high quality and affordable health care. Then we help governments and private industries apply those solutions locally.
My work with ACCESS Health has given me the opportunity to see incredible pockets of success throughout the world, but perhaps none quite as inspiring as what is taking place in newborn health in southern India.
Of the 2.7 million neonatal deaths globally in 2015, one third occurred in India alone.
Two years ago, two states in southern India - Andhra Pradesh and Telangana - launched a quality improvement program that generates simple, cost effective solutions to this considerable problem.
The program is called Safe Care, Saving Lives and is funded by The Children's Investment Fund Foundation. In Telangana and Andhra Pradesh, it is run in collaboration with the public health insurance program. The government subsidizes healthcare services at public and private facilities for more than 70 million people, including all those living below the poverty line. In 2014, Andhra Pradesh and Telangana decided that all facilities within their insurance network who work on maternal and newborn care would establish Quality Improvement Teams.
The teams are made up of healthcare providers working within the facility who are trained to analyze the causes of newborn deaths, and identify and test solutions. Each team has the opportunity to meet and learn from Quality Teams at other hospitals as well, as part of a Quality Improvement Collaborative. Teams can be set up and trained with very little cost, and have the potential to save tens of thousands of lives. Initial estimates suggest that Quality Improvement Collaboratives alone could reduce stillbirths and neonatal deaths by at least one quarter in the region.
Ringing the bell in Telangana
The work of each Quality Improvement Team differs depending on local problems, needs, and available resources. In Nalgonda, a town of roughly one hundred and fifty thousand people in Telangana, the district focused on a critical condition facing newborns: birth asphyxia. When babies are deprived of oxygen during the birth process for an extended period of time, it can lead to long term disabilities that include seizures, cerebral palsy, and neurodevelopmental delays. In Nalgonda, like many other hospitals in southern India, birth asphyxia was contributing to a significant number of admissions in the Special Newborn Care Unit.
The Quality Improvement Team conducted an exhaustive examination of current practices in the district hospital. While the team initially assumed a lack of knowledge or compliance with proper protocols was the root problem, they soon found that the real issue was actually a lack of communication between staff in the delivery room and those in the Special Newborn Care Unit. The nurses in the special unit were often unaware that a high risk newborn needed care and weren't able to treat the child in time, thereby increasing the risk of asphyxia.
The reason why staff in the delivery rooms and the Special Newborn Care Unit couldn't communicate was especially banal: the mobile phone network is not strong inside the hospital building and, without access to landlines, mobile technology was the primary means of communication. This meant that there was often only one staff member present in the labor room.
The solution cost practically nothing. The hospital strung a bell between the delivery room and the Special Newborn Care Unit. When there was a high risk delivery and nurses in the delivery room felt that special unit personnel would be needed, the delivery room staff rang the bell and additional nurses from the Special Newborn Care Unit would rush in.
Since the bell was introduced, there has been more than a twenty five percent reduction in asphyxia related admissions.
Preventing sepsis in Andhra Pradesh
The Quality Improvement Team in Nandyal, Andhra Pradesh, focused on another leading cause of neonatal mortality: life threatening infections. The goal was to bring down the number of cases of infection from thirty three percent to less than ten percent.
After an indepth analysis of current practice in the district hospital and best practices in other hospitals in the region and beyond, the Collaborative decided to establish a more rigorous handwashing and sanitizing routine for all staff in the delivery rooms and neonatal wards. In addition, it started enforcing the ideal insertion method for intravenous catheters - the Aseptic Non Touch Technique - to prevent infections during clinical procedures. It also standardized the way intravenous lines were inserted in newborns.
Thanks to these efforts, the number of infections among newborns in the hospital were drastically reduced. Enforcing the Aseptic Non Touch Technique alone resulted in a reduction of septic arthritis cases from an average of four cases per month to zero cases over a five month period.
Solving problems the simple way
The lesson from these two stories is simple: the ability to address many of the greatest health challenges lies within healthcare facilities themselves and the incredible people who are working on the frontlines. Challenges are identified by diving deeply into the data and identifying the bottlenecks and fundamental problems. Empowering staff to work together to tackle those problems is the next step toward improvement. Even in settings with very limited resources, significant improvements can be achieved in a very limited amount of time.
The Safe Care, Saving Lives program is working with several other states to see how they might replicate parts of the program. It is also in discussions with medical colleges across the country to introduce quality improvement in their curricula. To read more about the program, click here. Much thanks to the ACCESS Health team in Hyderabad for their contribution to this work.