Saving Mothers' Lives in Namibia

Saving mothers’ lives in Namibia

Namibia’s ongoing efforts offer lessons for other countries seeking to improve maternal health, as well as for health programs tackling HIV/AIDS, malaria, tuberculosis, or other conditions. 103

Kathleen Up to a half a million women die each year Preventable tragedies McLaughlin, around the world because of complications The global health community has long Marc van Olst, and arising from pregnancy or childbirth. The understood that improving the health of women Ronald Whelan, MD majority of these deaths occur in sub-Saharan during pregnancy, childbirth, and the Africa.1 Since they are largely preventable, postpartum period represents a massive oppor- they represent a tragedy playing out every day tunity not only to save women’s lives but also across the continent. Progress on maternal to improve neonatal, infant, and child health health there is hampered by health systems that outcomes directly. Further, most maternal are understaffed, underfunded, and over- deaths in low-income countries are preventable— whelmed—and thus too fragile and fragmented to arising largely from pregnancy-induced deliver the required level or quality of care. hypertension, hemorrhage, or sepsis. Still, up Consequently, many countries in sub-Saharan to a quarter of a million women die in sub- Africa will struggle to meet the United Nations’ Saharan Africa each year because of problems Millennium Development Goals for reducing associated with pregnancy or childbirth. child and maternal mortality by 2015.2 In Namibia, the incidence of maternal and Nonetheless, some countries are making neonatal mortality has doubled in recent years headway. Our recent work in Namibia, for (Exhibit 1). A woman in Namibia today is almost example, suggests that coordinated, targeted 100 times more likely to die during pregnancy interventions led by local stakeholders can than a woman in Europe. This difference partly accelerate improvements in maternal-health reflects Namibia’s high rate of HIV/AIDS outcomes. The key is to work with local health infection (more than 20 percent of the women at leaders to develop solutions that improve the the country’s antenatal clinics are HIV-positive) quality of health care, increase access to it, and and partly reflects limited access to health promote its early uptake. facilities (Namibia has the world’s second-lowest population density, with barely two people per The resulting interventions being pursued in square kilometer). Namibia are straightforward and practical—

1 World Health Organization improvements in the training of midwives, In a bid to stem Namibia’s rising maternal- (WHO), United Nations cheaper antenatal clinics inspired by the design mortality rate, the country’s Ministry of Health Children’s Fund (UNICEF), United Nations Population of shipping containers, operational fixes to and Social Services (MOHSS), in partnership Fund, and the World Bank, Maternal Mortality in reduce ambulance response times and wait times with McKinsey, the Synergos Institute, and the 2005, World Health at clinics, a radio talk show to educate patients Presencing Institute from the Massachusetts Organization, 2007. 2 In addition to meeting other and stimulate demand—yet are collectively Institute of Technology (MIT), established the social, educational, and powerful. A closer look at Namibia’s ongoing Maternal Health Initiative, or MHI (see sidebar, health targets, the United Nations seeks to reduce child efforts offers lessons for other countries seeking “About the initiative” on p. 110). It focuses on a and maternal mortality rates and drastically reverse to improve maternal health, as well as for health microcosm of Namibia’s health system to develop the spread of HIV/AIDS programs tackling HIV/AIDS, malaria, tuber- a replicable approach for improving maternal and malaria by 2015. For details, see un.org/millenniumgoals. culosis, or other conditions. health care across the country. 104 Health International 2010 Number 10

Health International 2010 Africa Namibia Health Exhibit 1 of 3

Exhibit 1 Maternal mortality has doubled in Namibia in recent years.

Namibia’s maternal-mortality ratio, deaths per 100,000 live births

225 in 1992 271 in 2000 449 in 2006

Source: Health and Social System Services Review, 2008, Namibia’s Ministry of Health and Social Services; Monitoring Emergency Obstetric Care, 2006; McKinsey analysis

The MHI chose to set up its pilot project in the mobilization, the capabilities of health workers, Khomas region, the most populous of Namibia’s and health system operations, respectively. 13 regions and the one with the worst uptake Each subteam included a variety of local front- of antenatal services.3 (Less than 7 percent of line health leaders and other stake holders—for pregnant women there receive antenatal check- instance, nurses, social workers, ambulance ups during the first trimester.) Within Khomas, drivers, and middle managers. the team focused on four of the largest suburbs of Namibia’s capital, Windhoek: Hakahana, Finally, to ensure local ownership and Katutura, Okuryangava, and Samora Machel, accountability (as well as to expand future which have a collective population of about initiatives across Khomas), a regional 80,000. It focused in particular on these areas’ delivery unit was established under the guidance busiest hospital and primary care clinics, of the chief medical officer in Khomas. It Katutura Hospital and Okuryangava Clinic, provides managerial oversight, monitors the 3 Common antenatal services respectively (Exhibit 2). performance of the region’s improvement include measuring blood pres- sure, conducting blood and in maternal health service delivery, and inte- urine tests, monitoring weight, taking fundal height measure- Next, three subteams were formed to design and grates the activities of the subteams with ments, and answering general develop prototype maternal-health solutions those of the health ministry’s regional team. questions about diet and fetal movements. for problems associated with community The subteams quickly identified and Saving mothers’ lives in Namibia 105

Health International 2010 Africa Namibia Health Exhibit 2 of 3

Where we worked: Inside the Maternal Health Initiative. Exhibit 2 Where we worked: Inside the Maternal Health Initiative.

Ohangwena Omusati Oshana

Caprivi Oshikoto Kavango Namibia Khomas region

Kunene Otjozondjupa Total population: Most densely populated of 2,047,000 Namibia’s 13 regions

Omaheke Life expectancy at birth: Region with highest Erongo 59 years (men) number of facility-based Khomas Windhoek 63 years (women) deliveries (8,915); nearly 19% of all such Total expenditure on health births in country per capita: $338 Around 7% of women get Hardap 49% of population lives antenatal checkups in the below international first trimester poverty line of $1.25 per day (2007) Karas An estimated 160,000 to 230,000 people (all ages) live with HIV (2007)

More than 60% of rural population lives farther than 5 km from a health facility and cannot afford transport; pregnant women often must travel on foot to reach a health care facility

Katutura Hospital Okuryangava Clinic

Situated in Katutura, The busiest clinic in one of the largest Khomas 1 km communities in Khomas, Situated in the heart of with ~40% of total Katutura, the clinic’s population of the region full-time nursing comple- Klein Windhoek(~80,000 people) ment of 8 registered Largest hospital in and staff nurses attend to the region, with 400−500 ~120 patients per day beds Antenatal patients in Waiting time at antenatal- 2007: 0 care clinic: ~6 hours

Note: Figures are for 2006 unless indicated. Antenatal patients in Source: World Health Statistics 2008 2007: 4,997 106 Health International 2010 Number 10

A woman in Namibia today is almost 100 times more likely to die during pregnancy than a woman in Europe

implemented several interventions to improve The quality of care during pregnancy was found to the supply of maternal care in Khomas and be significantly constrained by the lack of con- to raise demand for care among local women. tinuing education as well as by apathy and poor While it is too soon to claim victory over motivation among nursing staff. Mentoring Namibia’s maternal-health problems, the results and coaching practices have gradually fallen away thus far are encouraging. as a result of staff shortages and turnover in critical positions. Katutura Hospital, for example, Supply-side interventions has only one full-time gynecologist, and doctors Improving the access of patients to quality care is there do not typically stay in the department for a vital step in improving health outcomes. In more than two or three years. Khomas, the MHI and its local partners helped to bolster the quality of maternal care and to pilot In response, the MHI subteams worked with novel ways of adding capacity to the system. They the hospital’s superintendent and with nurses and also introduced efforts to squeeze greater doctors in the obstetrics department to develop capacity out of the region’s existing health assets. and institute a skill-building program for clinical personnel. One important component was the Raise the bar on quality creation of a mentoring role so that senior nurses In Namibia, the quality of maternal care has could identify, coordinate, and offer in-service deteriorated in recent years—a fact reflected in a training for nurses and nursing students. Next, 2006 survey from the MOHSS, which found health workers at the hospital engaged with nearby that less than 20 percent of the country’s midwives private hospitals and local training institutions could reliably diagnose and manage post- to learn best-practice training and clinical tech- partum hemorrhage. Further, the ministry found niques. The team also visited training that less than 40 percent of Namibia’s midwives institutions in Cape Town, South Africa, where its correctly monitored women in labor. What is more, members met with colleagues who had developed the MHI team observed that, not uncommonly, a best-practice curriculum and training manuals more than five different midwives attended for midwives. These moves led to efforts to to a woman in labor during her delivery (global standardize midwifery training in the region and best practice promotes individualized care). to the development of a skills-accreditation system. Saving mothers’ lives in Namibia 107

Within six weeks, Katutura Hospital had Expand access by adding capacity developed its own in-service training curriculum More than 60 percent of Namibia’s rural and concluded its first training program. population lives five kilometers or farther from a Subsequently, the nurses we interviewed re- health facility, and many people cannot ported feeling more confident in their afford transport to faraway clinics or hospitals. ability to coach and mentor one another and to This reality was driven home for us when we provide better care to patients. In-service encountered a group of pregnant women living training sessions are now held weekly, and under a tree outside a hospital in largely rural program coordinators continue to look for best northern Namibia. Some of the women had been practices and innovative training methods. living there five months because they were Further, to keep quality high, the MHI is intro- afraid that they would not be able to reach the ducing a formal process to investigate hospital in time once they went into labor. maternal deaths so that their causes can be determined and similar deaths prevented. The situation is nominally better in urban Katutura, where only the two hospitals provided Finally, the hospital set its sights on shortening antenatal care before the MHI. To get proper the antenatal unit’s waiting times—over six treatment, most women in the Khomas region hours, in most cases. The unit reduced them by had to walk more than five kilometers to 30 percent in less than a month by making reach a medical facility—and repeat the journey a series of simple process changes: for instance, at least five or six times during their pregnancies. introducing a numbered ticket system for people arriving at the hospital and allowing A team of MHI participants therefore worked patients to keep their records instead of handing with a local NGO to help design a “container them back to the charge nurse upon completing clinic” prototype that could be set up in outlying each of the nine stages of consultation. To areas to increase access to care for rural women. encourage staff to focus on customer service, the The clinic—dubbed “CWIClinic” as a play on the unit created a patient satisfaction survey, whose word “quick” and an acronym for child, women, results are posted daily, along with average and infant clinic—is a modular, prefabricated, waiting times, to encourage further improvement. 15-square-meter structure the size and shape of

To get proper treatment, most women in the Khomas region had to walk more than five kilometers to reach a medical facility—and repeat the journey at least five or six times during their pregnancies 108 Health International 2010 Number 10

Opening time at Okuryangava Clinic (October 2009).

The Okuryangava Clinic’s staffers see its first antenatal patient (October 2009).

a shipping container. It can be assembled in just Improve efficiency 48 hours, includes a fully equipped examining Another powerful means of expanding access room and a small administrative office, and costs to health care in Africa would be to use 25 percent less than a similarly sized perma- existing facilities and resources more efficiently, nent building (Exhibit 3). Nurses employed by so that they can serve larger numbers of the NGO (the Namibia Planned Parenthood patients. During the project, the MHI team Association) staff the clinic and receive special attempted to realize this goal in two ways. refresher training at Katutura Hospital to ensure high-quality care. First, the team worked with Okuryangava Clinic to see if it could offer antenatal care. In anticipation of efforts to test the concept’s Namibia’s health ministry had long wanted to feasibility in rural areas, different versions provide it in urban clinics to make access of the clinic are being equipped with solar easier and more affordable for patients but had panels, a septic tank, and a stand-alone tank to been frustrated by shortages of staff and space. supply fresh water. The results have been promising. In fact, Namibia’s health ministry, in While these shortages were a constraint, so partnership with the NGO, now aspires to roll was the mind-set of clinic staff. Many out such clinics across the country and has nurses felt that offering antenatal care at the submitted plans to Namibia’s finance ministry clinic was simply impossible given existing to mobilize funding for 16 additional clinics. staff levels. Therefore, a big task was to get the The health ministry has also identified a site for local nurses energized and involved. The a second CWIClinic in Khomas. team achieved this goal, in part, by working Saving mothers’ lives in Namibia 109

Setting up a CWIClinic is truly quick

Within 48 hours of pur- chase: a modular, prefab- ricated 15-square-meter structure is transported to and assembled on site

Within 72 hours on site: the structure is connected to electricity and water

Health International 2010 Africa Namibia Health Exhibit 3 of 3

Exhibit 3 The prototype container clinic brings antenatal care to outlying areas.

Prototype CWIClinic (child, women, and infant clinic)

Sample layout for container-sized structure

Supply cabinet Fridge

Oxygen Basin

Bed Chair

Stool Desk 110 Health International 2010 Number 10

About The Maternal Health Initiative (MHI) is part of a larger MHI was created in partnership with Namibia’s Ministry of the initiative project designed and supported by a partnership Health and Social Services (MOHSS). The aim was to among Synergos Institute (an international NGO and the promote locally developed maternal-health-improvement in-country partner in Namibia), the Presencing initiatives, build local leadership capacity, and improve Institute from the Massachusetts Institute of Technology alignment among the MOHSS, the country’s civil society (MIT), and McKinsey. The project, funded by the organizations, the private sector, and other development Bill & Melinda Gates Foundation, is testing ways to im- partners. The 20 participants of the pilot MHI team, from a prove health service delivery in developing countries range of backgrounds and levels within the health system, rapidly by combining leadership development with coordi- include nurses, doctors, private health care providers, nated operational and organizational changes. The goal NGOs, and academic institutions. is to create a replicable model that can be applied within or across disease programs in national health systems.

with nurses to show how simple operational The second way the MHI team used efficiency changes could free up time. By using gains to expand access was to cut the excessively straightforward diagnostic tools common in long response times of ambulances (90 minutes, lean-manufacturing environments (for on average). In fact, ambulances failed to answer instance, spaghetti diagrams to pinpoint about half of all emergency calls because they wasted process steps visually), the nurses were otherwise occupied. When the team looked identified bottlenecks and addressed them. closer, it found that up to 70 percent of the trips of the community’s five ambulances involved As the nurses saw the improvements take hold, non-emergency cases. Moreover, critical radio they changed their minds about what was communication equipment was broken, possible and began enthusiastically backing the dispatching procedures were largely ad hoc, and antenatal care pilots. Within four weeks, the ambulance repairs took several weeks. The nurses had found ways to free up space and MHI team helped ambulance drivers work with staff schedules and had seen their first the health ministry to prioritize the repair of antenatal patient (after receiving refresher radio equipment, streamline requests for vehicle antenatal training at Katutura Hospital). In repairs, train a specialized dispatcher, and large part because of the nurses’ enthusiasm as develop a simple dispatch protocol. Moreover, the “change agents,” other clinics in the region team helped to mobilize funding (through the began investigating similar changes. Within health ministry) for a minibus specifically intended five months, all of the region’s 11 primary care to provide nonessential medical transport, thus clinics were offering antenatal care. freeing up ambulance capacity. Saving mothers’ lives in Namibia 111

A health ministry official discusses the new performance-measurement system with employees at the Katutura Expectant mothers wait for ambulance station (September 2009). their first antenatal checkups at Katutura Hospital (June 2009).

Within a month, average response times had antenatal care present themselves for their first decreased by 60 percent and the proportion visit well into the third trimester—when it is of emergencies handled within 30 minutes had often too late to manage problems. more than doubled, to 55 percent, from 23 percent. To encourage improvement and keep drivers On closer examination, the MHI team found that focused on results, the ambulance service began this behavior reflected not only poor access using performance-management whiteboards to antenatal care but also the prevailing lack of to track drivers’ response times and the availability awareness among local women about its of ambulances. Consequently, average response importance. Many women the team talked to times have consistently remained below half an did not, for example, know the basic risks hour for more than six months. associated with pregnancy, including the potential transmission of HIV/AIDS to their babies. Demand-side interventions Improving the supply and quality of health care To address these knowledge gaps, the team is the first priority for governments seeking worked with Namibian education and better maternal-health outcomes. However, health health officials to create a weekly, 45-minute systems must also educate patients so that they reproductive-health show for a local radio station. know about and seek the potential life-saving (Radio is well suited to spread information interventions and treatments available to effectively among rural populations that may be them. Stimulating demand for services is therefore widely dispersed or have low literacy rates.) critical. In Khomas, the central challenge was The show, which first aired in August 2009 and to spur demand for antenatal services. is hosted by influential radio personalities with strong ties to the local community, focuses on Raising awareness promoting good maternal-health practices. The Less than 7 percent of the pregnant women messages include the benefits of early antenatal in Khomas receive antenatal checkups care and deliveries in hospitals, the danger during the first trimester of pregnancy. signs during pregnancy, and family-planning Almost 40 percent of the women who receive options and postnatal care. 112 Health International 2010 Number 10

The show’s format includes call-in segments where Other incentives are less obvious, though listeners anonymously share their stories, ask surprisingly powerful. The MHI team quickly questions, and receive immediate expert medical discovered, for instance, that what women in input from a guest panel of health workers. Khomas particularly valued during their Broadcast in six different local languages, the show antenatal checkups was the ultrasound, as it appears to be quickly gaining popularity among allowed them to see their babies for the first local women and is a hot topic of conversation time. Consequently, the team is arranging for among women in Khomas’s antenatal clinics. the antenatal clinic at Katutura Hospital to Encouragingly, the MHI team observed that a offer women one free ultrasound picture during high proportion of callers are men, suggesting that their pregnancies to encourage earlier and the anonymity of the show’s format encourages greater participation. The prospect of getting that them to ask candid questions about reproductive first baby picture has thus far proved a potent health. This is good news, because one reason incentive to seek antenatal care. the region’s women do not seek antenatal care is a fear that their partners will not approve.

To increase the show’s impact, members of the While much work remains be done in Namibia, MHI team are creating a spin-off radio serial our experience there demonstrates that drama in a “soap opera” format to reinforce the focused interventions harnessing the efforts of messages. Students at the Katutura media local leaders, together with simple changes school will support this new show, which will in operating practices, can free up significant feature fictitious Namibian characters displaying capacity in health systems and quickly improve both good and bad health habits. The show health outcomes for mothers and their babies. has generated interest from four national radio stations, as well as from local newspapers The authors wish to thank Doan Hackley, Len le Roux, Thokozile Lewanika, Kasee Mhoney, Rushad Nanavatty, that plan to introduce the fictional radio characters Rui Neves, Sabine Schulz, Marilyn Shivangulula, and into their comic strips to promote the show Shrey Viranna for their significant contributions to this and its messages. article and the field work that underpins it.

User incentives Kathleen McLaughlin is a director in McKinsey’s The use of simple incentives is the last way the Toronto office;Marc van Olst is a principal in the Johannesburg office, whereRonald Whelan, MD, team is attempting to stimulate demand for is a consultant. antenatal services in Khomas. The radio show, for instance, plans to introduce quizzes on family health–related topics. These quizzes can be quite powerful: in Uganda, for example, the mobile provider Celtel recently supported an interactive, text message–based quiz about HIV/AIDS that used free airtime as an induce- ment for users to play. During the pilot, the number of people seeking HIV tests increased by 40 percent.