Health system building block | Challenges | Potential solutions |
---|---|---|
Leadership and governance | • Absence of a national policy or strategy on audit • Lack of data collection tools mortality audit meeting guidelines • Lack of prioritisation of audit by policymakers • Culture of blame and fear of potential legal ramifications • Lack of awareness and use of data by government officials • No champions | • National policy with clear implementation plan and decision-tree based on entry-points and system capacity • Standardised tools (paper-based and electronic) available for adaptation at global level • Training for facilitators both integrated into intrapartum care training and stand-alone • Legal protection • High level buy-in for collection and use of data (e.g. from President or Minster of Health) |
Health finance | • Lack of funding for audit tool development locally • Training and supervision not currently budgeted • Software and electronic platforms may pose additional financial burden • Opportunity cost of audit committee meetings | • Advocate for inclusion of audit in budget for national and sub-national quality improvement processes • Cost the additional benefit of removing avoidable factors in comparison to extra time spent dealing with missed opportunities |
Health workforce | • Overburdened staff do not have time for meetings • Fear of blame, inter-disciplinary mistrust and professional power hierarchies | • Identify champions to lead and participate in the audit committee who will engage not antagonise • Legal protection and confidentiality |
Essential medical products and technologies | • Stationery not available for patient records necessary to complete audit • Lack of electronic system means paper-based forms lost, or data not aggregated and shared | • Prioritise stationery procurement • Develop easy to complete patient charts and checklists • More effective records management and retrieval |
Health service delivery | • Administration is responsible for many of the necessary changes outside of health worker control | • Ensure facility administrators are members of the audit committee with responsibility to attend meetings periodically if not always • District administrators receive specific, actionable requests from the audit committee |
Health information system | • Lack of a centralised database for compiling audit results • No system for notification of perinatal deaths at any level • Poor capacity to use and interpret statistics and create actionable recommendations | • Where practical, consider the use software that generates run chart data, simple graphs, and provides prompts and checklists for addressing recommendations arising from audit |
Community ownership and partnership | • Community representatives are rarely engaged in the audit process or informed of the findings • Only facility deaths captured; inequitable representation of true burden of disease and avoidable factors in the community | • Engage a community liaison as a standing member of the audit committee with appropriate confidentiality requirements • Consider community surveillance to inform about perinatal deaths that occur outside the facility and conduct verbal and social autopsy, where feasible |