New Clinical Standards Provide Liberian Health Workers With Tools to Improve Care

{Photo credit: MSH}Photo credit: MSH

For many Liberian women, the excitement of pregnancy is often accompanied by cautious fear. Too many of these women have experienced pregnancy complications themselves or know others who have suffered or died from hemorrhage, blood clots, infection, high blood pressure, or obstructed labor. While these complications pose serious dangers for all pregnant women, Liberian mothers face the added risk of a weak health system that often leaves them in the hands of untrained staff and ill-equipped facilities. The result is that, for every 100,000 live births, 770 Liberian women die.

In 2008, to address these and other urgent health needs, the Government of Liberia developed a basic package of health services offering free disease treatment, dental and eye care, emergency care, and maternal and child health care to all Liberians. Although this package increased access to care, many of the nation’s health workers did not possess the knowledge needed to effectively provide all of the services. In response, Liberia’s Ministry of Health and Social Welfare (MOHSW) developed an essential package of health services (EPHS) that emphasized the most critical service needs (i.e., maternal health, child health, and care for vulnerable populations) and worked with the US Agency for International Development (USAID)-funded Rebuilding Basic Health Services (RBHS) project to develop clinical standards for EPHS implementation.

Clinical standards provide health workers with clear, detailed instructions for patient triage, diagnosis, and treatment. For example, to reduce the risk of hemorrhage during and after labor, the standards instruct clinicians to regularly measure women’s blood loss during delivery, administer a uterotonic soon after the delivery, clamp the umbilical cord following uterine contraction, and deliver the placenta by controlled cord traction. Detailed instructions such as these help health workers monitor and treat women for hemorrhage and other complications early enough to save their lives.

Developing Standards to Improve Clinician’s Knowledge 

To develop the most clear and accurate clinical standards, RBHS helped the MOHSW establish a system for developing, testing, reviewing, approving, and rolling out each set of standards. Led by JSI Research & Training Institute, Inc. and in partnership with Management Sciences for Health (MSH), RBHS worked closely with the ministry’s field clinicians, academic staff, medical experts, and other stakeholders to ensure they had the skills and knowledge needed to develop the full spectrum of clinical standards and to keep these standards up-to-date.

These efforts enabled the MOHSW to develop outpatient clinical standards in 2010 and inpatient clinical standards for infection prevention and neonatal and obstetrics care in 2012. The ministry then used the skills they’d obtained from RBHS to develop additional clinical standards for sexually transmitted infections, HIV & AIDS, malaria, tuberculosis, emergency care, nursing care, and surgical procedures.

Implementing Clinical Standards through Collaboration and Accountability 

To support improved service delivery capacity, RBHS and MSH helped the ministry implement three sets of clinical standards at four government hospitals using an “improvement collaborative” approach. This approach involved forming four teams of staff from hospitals and the MOHSW and teaching them how to use the clinical standards and develop quarterly implementation work plans. The teams now meet each quarter to share their implementing challenges, solutions, and achievements. They also benefit from regular ministry site visits and on-the-job staff training. Furthermore, RBHS, MSH, and the MOHSW have developed a set of indicators for the most critical standards and trained supervisors to conduct quarterly assessments measuring facilities’ performance against these indicators.

"[We] use these tools to show supervisors how to be effective. Before, supervisors were only observing. Now they can show staff their errors and help them improve," said Sam Ticker, a community health department director in Grand Bassa County.

RBHS and MSH are now helping the MOHSW develop a plan for rolling out the clinical standards to additional hospitals in the coming year. Every day, more health workers are using clinical standards to identify health risks, diagnose illnesses, and provide timely, effective care and treatment. As a result, fewer women are dying during labor and more Liberians are coming to trust the health system as a source of dependable, high-quality care that saves lives.