The Uthukela Integrated Nutrition Project
Appropriate interventions to improve maternal and child health are available in all public health facilities in South Africa and primary health clinics are well utilized by mothers and their children. Yet, many mothers were not able to access a comprehensive range of essential services for themselves and their children on the same day, which meant mothers had to make several visits to the clinic to receive all the care they needed.
UNICEF provided funding support in 2012 to develop, in collaboration with the KZN Department of Health (DoH), a framework for the integrated provision of HIV and MCH services in the well-child setting. Additional funding was received by Dr Christiane Horwood who was awarded funding from UCSF RAP International Mentored Scientist Research Award Programme in HIV/AIDS. Working with the DoH in Uthukela District in KZN, barriers and challenges to providing integrated care were identified including the flow of mothers through the clinic, which health workers were providing care to mothers and their children, and if they had access to the essential equipment needed to provide care to mothers and their children. Many missed opportunities for health workers to provide comprehensive integrated maternal, child and women’s health services to mothers and babies when attending well-child clinic visits were identified and a comprehensive package of care to be provided to all mothers and their babies at every well-child visit was developed. A framework to restructure clinics was proposed to improve the flow of mother through the clinic to ensure they were able to access all essential services every visit. Because of the fundamental role of professional nurses in prescribing crucial medications which other health worker cadres were unable to provide, amendments were made to guidelines to ensure every mother and child pair was seen by a professional nurse at every visit.
Between September 2013 and November 2014 UNICEF and RMC provided funding to test these changes in five clinics in Uthukela. Using a structured data-driven quality improvement methodology, regular two-weekly mentoring visits and quarterly peer-to-peer learning sessions were undertaken to drive integration of services in the five pilot clinics. All health facility staff as well as the community caregivers attached to the five clinics were involved in the improvement activities. Despite intensive mentoring and support at the end of the study period, there were no significant improvements in growth monitoring of infants and young children. However, there were significant improvements in a number of essential services offered to mothers and their infants.
Given the improvements from the proof of concept intervention undertaken in Uthukela, in 2016 UNICEF provided ongoing funding to ensure the whole of Uthukela district benefitted from this important intervention. A robust step-wedge study design was used to roll out a rapid, scalable quality improvement intervention to the remaining four sub-districts and their clinics in Uthukela. Using this methodology allowed for a comparison between control clinics (before the intervention was rolled out) and intervention clinics (after they received the intervention). The intervention was based on the quality improvement model tested in the previous funding cycle using the original package of comprehensive care to be provided by health workers from the initial funding. While there were significant improvements in some of the maternal and child health services provided as a result of this intervention the intervention was not able to make the substantial changes required to provide the full comprehensive package of services to all mothers and children at a single visit. Intractable health system challenges contributed to lack of success in a number of the elements of the comprehensive package of care. If this intervention is to be adopted in other health settings, special attention would need to be focused on health systems strengthening required to support quality improvement at a clinic level.
