Knowledge Brief Health, Nutrition and Population Global Practice BUILDING HIGH-QUALITY HEALTH SYSTEMS TO IMPROVE NUTRITION SERVICES FOR WOMEN AND CHILDREN: POLICY AND IMPLEMENTATION CONSIDERATIONS Silvia Holschneider, Ali Winoto Subandoro, Julie Ruel-Bergeron, and Leslie Elder August 2022 KEY MESSAGES: • A high-quality health systems approach that integrates nutrition is vital to accelerate progress in nutrition and meet the Sustainable Development Goals by 2030. • High-quality health systems for nutrition include integrated service provision and supplies, performance monitoring, strategic purchasing, and functioning referral services. • Underpinning these components are political leadership and commitment, well-defined quality metrics and quality and timely nutrition data, and an accountability system that nurtures demand for quality services, among others. • Several World Bank and Global Financing Facility (GFF)–cofinanced projects are investing in building high-quality health system foundations to improve the quality of nutrition services and can serve as examples for improving quality of nutrition care. Introduction sustained focus on improving the quality of nutrition Malnutrition for women and children—especially during the services for women and children is needed. This brief first "1,000 days"—continues to be a significant problem in provides an overview of a high-quality health systems many low- and middle-income countries (LMICs) despite approach for improved nutrition outcomes. It also gives substantial progress made during the last decade. examples of how the World Bank and Global Financing Providing access to evidence-based nutrition interventions Facility (GFF) have supported country-led efforts and is essential but insufficient. Numerous studies from LMICs country leadership in health system strengthening and have shown that many high-impact nutrition-specific explains how these investments are helping countries lay interventions are either not delivered consistently or with some of the needed foundations for high-quality health sufficient quality during key maternal and child health systems for nutrition. contact points (World Bank 2018, 2020; Billah 2022). For What is a high-quality health system for example, nutrition service delivery and counseling are nutrition? often neglected or sidelined during antenatal care (ANC), newborn care, postnatal care (PNC), and well-child visits, Figure 1 shows the Lancet High Quality Health Systems resulting in incomplete and/or poor quality of care (USAID framework we have adapted for nutrition. Improved 2021). This has also been demonstrated in the Lancet nutritional outcomes, user confidence, and economic Global Health Commission's report on High Quality Health benefits are influenced by improved processes of nutrition Systems in the Sustainable Development Goals Era care, and improved foundations for nutrition (e.g., including (HQSS), which estimates that 60 percent of 8.6 million political leadership and commitment to improving quality of health-related deaths in LMICs are due to poor quality care, nutrition care, quality and timely nutrition data and and the remainder are due to the nonutilization of the health performance monitoring systems, predictable and system. adequate financing for nutrition, improved access and organization of nutrition services, a competent workforce, With only seven years left to achieve the Sustainable adequate supplies and equipment, and a system that Development Goals (SDGs) by 2030, a renewed and Page 1 HNPGP Knowledge Brief Figure 1. A High-Quality Health Systems Framework for Nutrition For People QUALITY IMPACTS Be�er health and nutri�on Confidence in system Economic benefit PROCESSES OF CARE Competent nutri�on care and systems Posi�ve user experiences FOUNDATIONS M&E and Governance Financing Pla�orms Workforce Tools Popula�on data use • Strong leadership • Convergent easy- • Predictable, • Improved access • Sufficient • Adequate • System that and coordina�on to-use adequate, and and organiza�on distribu�on and nutri�on responds to • Harmonized informa�on �mely financing of care numbers supplies and client’s health nutri�on strategies , systems that for nutri�on • Func�onal • Competent health equipment and nutri�on guidelines , and collect nutri�on services referral systems workers needs and targets informa�on for nutri�on knowledgeable in expecta�ons • Robust regulatory • Quality nutri�on nutri�on and quality data for learning • Sound suppor�ve improvement and improvement supervision mechanisms systems equitable resilient efficient Source: Adapted from (Kruk et al. 2018) responds to clients' health needs and expectations). In from the national to the subnational levels to ensure addition, high-quality nutrition systems should be for the effective implementation and compliance with nutrition and people, equitable, resilient, and efficient (Holschneider et quality-related policies and strategies at all levels of the al. 2021, Kruk et al. 2018). system (Subandoro, Holschneider, and Ruel-Bergeron 2021). Foundations and processes of care Indonesia and Rwanda provide good examples of how Governance through improved leadership and quality high-level political leadership and ownership have paved improvement mechanisms the way for the development and implementation of The World Health Organization Maternal, Newborn, Child multisectoral nutrition strategies and institutional and Adolescent Health (WHO MNCAH) Quality of Care arrangements that include coordination strategies, (QoC) Standards and QoC Network emphasize the monitoring, reporting, accountability systems, and funding importance of political leadership and commitment to frameworks from national to subnational levels improving the quality of nutrition care in MNCAH services, (Subandoro, Holschneider, and Ruel-Bergeron 2021). along with evidence-based nutrition content in national These plans, however, could benefit from a more explicit MNCAH and nutrition quality policies, strategies, and mention of how quality will be improved, including the documents (USAID 2021). Quality nutrition services also capacity of subnational governments to manage, finance, require that formal institutional coordination and and ensure high-quality delivery of their nutrition programs. implementation arrangements are replicated and aligned Page 2 HNPGP Knowledge Brief Accreditation of health care facilities is a form of Financing government regulation to help ensure compliance to Financing is an opportunity to improve health system standards, and, ideally, quality. However, accreditation performance, including for nutrition services. According to leads to improved quality of care and outcomes only when the Lancet HQSS, strategic purchasing 1 of nutrition it is part of a "package" of interventions, and the data services has the most significant direct influence on quality gathered become a learning system and are translated into of care (Kruk et al. 2018). It entails prioritizing nutrition in action (Kruk and Nimako 2020). resource allocation and service delivery and creating incentives at the health facility level to strengthen access Monitoring and Evaluation (M&E) and data use for to and improve the quality of nutrition services. Strategic decision making purchasing also relies on robust information systems to Improving the availability of quality and timely nutrition data help monitor performance (i.e., are services being and performance monitoring systems is key to enhancing delivered at the scale and quality to meet purchaser program implementation and accountability. Most LMICs expectations?) (Subandoro, Holschneider, and Ruel- collect nutrition-related data through multiple data sources. Bergeron 2021). However, data integration, accuracy, availability, and granularity at community and district levels remain Performance-based financing (PBF) has the potential to challenging (Acosta and Fanzo 2012). improve strategic purchasing functions. Quality-adjusted strategic purchasing of essential health services, including Countries should also, ideally, be including nutrition quality nutrition, should be an essential aspect of PBF. Given the of care measures in their facility-level data and routine widespread use of PBF in LMICs to improve quantity and health information systems. The WHO has developed quality, there is a lot of potential to improve key quality quality of care standards and corresponding measures to measures beyond service availability and readiness by improve the quality of maternal and newborn child services integrating quality indicators and methods into PBF to in health facilities (WHO 2016, 2918). These include measure quality (Fritsche and Peabody 2018). In Rwanda, numerous nutrition-specific quality statements and health centers are being supported and incentivized measures. Examples of quality measures include the through PBF to improve the quality and coverage of an availability of up-to-date clinical protocols, adequate and enhanced package of high‐impact nutrition and health functioning equipment, in-service training, compliance with interventions for women and children (Subandoro, Code of Marketing of Breastmilk Substitutes, effective Holschneider, and Ruel-Bergeron 2021). Several indicators systems for implementing community-based activities, etc. measure quality including stock-outs of essential drugs and (USAID 2021). provision of supportive supervision to community health While many countries are implementing innovative workers. At the community level, improved community measurement and data-collection tools, the impact on health worker (CHW) performance is incentivized through quality nutrition services depends on how data are being evaluation and performance-based remuneration to CHW effectively used to inform decision making and enable cooperatives and individuals. course correction for improvement. Timely feedback and In the World Bank and GFF–cofinanced Cambodia performance comparisons are needed to promote ongoing Nutrition Project, provider knowledge and competencies quality improvement. are measured through clinical vignettes and exit interviews, In Indonesia and Rwanda, the World Bank and GFF are with PBF as incentives for quality improvement (see working with the government to develop performance “Workforce” section below). Additional examples to monitoring dashboards to consolidate and standardize measure the quality of provider competencies that are data to measure health and nutrition-related performance, being used in other countries include chart reviews, direct including across sectors and at district level. Data are used provider observations, mystery patients, and client to track implementation progress of their nutrition satisfaction surveys (Fritsche and Peabody 2018). strategies and to inform discussions at national and district Platforms for care and “tools” for quality nutrition levels. Efforts should be made to more explicitly include interventions quality of care measurements for nutrition services, as High-quality health systems ensure that quality nutrition opposed to solely focusing on gaps in service delivery services are provided at various service delivery points to (Subandoro, Holschneider, and Ruel-Bergeron 2021). provide clients access to care. They also require integrated health facility and community-based services, outreach, 1 Strategic purchasing ties the payment of providers to information that links their performance to the health/nutrition needs and outcomes of the population they serve, thus incentivizing quality services. Page 5 HNPGP Knowledge Brief and functioning referral systems. Improving access to and/or are of low quality due to lack of time for counseling quality nutrition services relies heavily on community- and provision of generic or prescriptive messages that fail based platforms to reach those most in need. Robust to resonate with caregivers. supportive supervision and performance management by Digital tools are increasingly being used to improve health the health facility are needed to ensure delivery of quality providers’ capacity to deliver high-quality nutrition services. nutrition services by these community-based platforms. As In Indonesia, for example, a digital monitoring and mapping a key principle of people-centered health systems, application for Human Development Workers (e-HDW) is communities should be empowered to more actively be being rolled out to simplify the reporting and tracking of engaged in planning, implementation, and evaluation of nutrition-related services across multiple sectors, while their own local nutrition programs (Schwarz et al. 2019). also serving as a job aid to improve the quality of nutrition To enhance quality of integrated frontline health systems, service delivery and counselling (Holschneider et al. 2021). the WHO QoC network has promoted continuous quality In the Cambodia Nutrition Project, clinical vignettes 2 and improvement (QI) at the health facility and community level competency tests are being used at the health facility level as an important approach to identify the WHO QoC gaps, to measure and improve what the health staff knows about analyze the bottlenecks in the provision of services, test Maternal, Newborn, Child Health and Nutrition (MNCHN)– and adopt changes, and continuously measure trends in related medical conditions, their adherence to evidence- QoC indicators to guide QI efforts and improve outcomes based interventions and guidelines (including nutrition (WHO 2022). during the first 1,000 days), and their competency to deliver care and counsel patients. The results feed into the Quality health systems need functional equipment, quality MNCHN scorecard as described above (Subandoro, medicines, and reliable supply chains for all service Holschneider, and Ruel-Bergeron 2021). delivery points offering nutrition services. Many health facilities in LMICs lack these essential nutrition “tools.” The Population demand for high-quality care Cambodia Nutrition Project ensures the availability of these High-quality nutrition systems enable clients to demand critical resources (equipment, supplies, medicines, and accountability from their communities and health systems. guidelines) through a facility-level scorecard, the outcomes Numerous World Bank and GFF–cofinanced nutrition of which are tied to PBF (Subandoro, Holschneider, and projects actively engage communities in their nutrition Ruel-Bergeron 2021). interventions. For example, in Indonesia and Rwanda, Though this brief focuses on the importance of high-quality scorecards hold village and subdistrict heads accountable health systems for nutrition, it is important to note that for delivering nutrition-specific and sensitive services quality nutrition platforms also require collaboration across (Subandoro, Holschneider, and Ruel-Bergeron 2021). nonhealth sectors to work together and address nutrition They help identify service gaps; track progress on problems. For example, the life-course approach to child multisectoral convergence of services; and trigger health and development integrates health, nutrition, and conversations between the community, service providers, early childhood development from birth to adolescence. and the local government to resolve the service gaps. This requires collaboration across health and nonhealth Ideally, however, these scorecards should not only focus sectors to maximize the reach of service delivery across on coverage but also include measures of quality. In the various platforms accessed by target populations (Kruk Cambodia, the MNCHN scorecard measures patient and Nimako 2020). feedback regarding nutrition services—another important element of ensuring that services meet client health needs Workforce and expectations. Competent health workers are essential for delivering High-quality systems for nutrition also encourage quality nutrition services and counseling. Nutrition service individuals, their families, and communities to be well- delivery challenges in many LMICs include low provider informed about optimal nutrition practices through quality training and capacity to implement evidence-based nutrition counseling and education (USAID 2021). There is nutrition practices; limited accountability for providing ample evidence that interpersonal communication and nutrition and immunization services in adherence to counseling (IPCC) can improve nutrition practices during country guidelines; inadequate supportive supervision; and the first 1,000 days, but that nutrition counseling is often insufficient job aids to carry out the work. Nutrition not carried out effectively (Lamstein et al. 2014). Studies counseling interventions and growth monitoring and show that the quality of IPCC is more effective when other promotion (GMP) are often left to providers' discretion social behavior change communication (SBCC) activities asks the health worker how he/she would manage the patient—are being 2 MCHN vignettes—or standardized medical cases where an assessor developed to improve provider counseling on MCHN as well as adherence role plays a mother with a sick child or a woman seeking services and to evidence-based interventions and guidelines. Page 4 HNPGP Knowledge Brief are aligned on messaging and reinforce the counseling 2022. “Factors Influencing Quality Nutrition Service Provision at Antenatal Care provided to other IPCC contacts (e.g., mothers, fathers, Contacts: Findings from a Public Health Facility-Based Observational Study in 21 etc.) (Lamstein et al. 2014; Menon et al. 2016; Nguyen Districts of Bangladesh." PLoS One 17 (January 1): 1–18. 2017). Fritsche, G., and J. Peabody. 2018. "Methods to Improve Quality Performance at Scale in Lower- and Middle-Income Countries." J Glob Health 8 (2): 1–15. Recommendations Kruk, M. E., A. D. Gage, C. Arsenault , K. Jordan, H. H. Leslie, S. Roder-dewan, et al. 2018. The This brief describes promising approaches and entry points Lancet Global Health Commission High-quality Health Systems in the Sustainable in World Bank and GFF–cofinanced health and nutrition Development Goals Era : Time for a Revolution 6 (November): 1196–252. projects for improving the foundations and processes for Kruk, M. E., and K. T. Nimako. 2020. “Building High Quality Health Systems: Global Financing high-quality health systems for improved nutrition care. Facility Investment Options.” Washington, DC. Additional approaches for building high-quality health Holschneider, S., A.W. Subandoro, E. Karjadi, A.M. Provo, R. Herkutanto, P. Ayuningtyas, A. systems for nutrition include the following: Dharmawan, M.N. Sudarjo. 2021. “Improving the Quality of Frontline Nutrition Services in Indonesia’s Health Sector.” World Bank: Washington, DC. Government and partners conduct a diagnosis of the Lamstein, S., T. Stillman, P. Koniz-Booher, A. Aakesson, B. Collaiezzi, T. Williams, K. Beall, and strengths and weaknesses in the foundations for high- M. Anson. 2014. "Evidence of Effective Approaches to Social and Behaviour Change quality health systems for nutrition to decide on Communication for Preventing and Reducing Stunting and Anemia: Findings from a specific investment options. This includes the current Systematic Literature Review." Arlington, VA: USAID/SPRING Project [Internet], 116. functioning of governance (e.g., leadership, quality of Menon, P., A. Khaled, J. Baker, K. Afsana, E. A. Frongillo, T. Sanghvi, J. Baker et al. 2016. nutrition strategy/guidelines), financing, workforce, tools, "Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media platforms for care, and population demand for nutrition Campaign Has Large Differential Impacts on Complementary Feeding Practices But (Kruk and Nimako 2020). Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Work with government counterparts at national and Bangladesh." J Nutr. 146 (10): 2075–84. subnational levels to ensure that high-quality Health Nguyen, T. T., S. Alayón, A. Jimerson, D. Naugle, P. H. Nguyen, N. Hajeebhoy, J. Baker et al. Management Information Systems (HMIS) and metrics 2017. "The Association of a Large-Scale Television Campaign with Exclusive exist to facilitate the implementation of quality of care Breastfeeding Prevalence in Vietnam." Am J Public Health 107 (2): 312–18. for nutrition. This includes reviews of existing data Schwarz, R., M. Matheke-Fischer, H. Ladha, and A. W. Subandoro. 2019. "The Frontline Health systems and nutrition indicators (including those Care System Resource Toolkit." Washington, DC. measuring quality), interoperability of data systems, and Subandoro, A. W., S. Holschneider, and J. Ruel-Bergeron. 2021. “Operationalizing Multisectoral access and use of nutrition data across all levels of Nutrition Programs to Accelerate Progress: A Nutrition Governance Perspective.” government. The WHO and QoC network have developed World Bank: Washington, DC. valuable tools and implementation guides for countries to USAID (United States Agency for International Development). 2021. "Nutrition Quality of Care for develop their own quality health strategies, which can be Maternal, Newborn, Child, and Adolescent Health." Washington, DC: adapted for nutrition and local contexts (WHO 2022; USAID/Momentum. WHO/UNICEF 2019). WHO (World Health Organization). 2016. "Standards for Improving Quality of Maternal and Newborn Care in Health Facilities." Geneva. Work with government counterparts to test health WHO. 2018. “Standards for Improving the Quality of Care for Children and Young Adolescents in systems innovations for quality nutrition services. Health Facilities.” Geneva. Outcomes for systems innovations can include WHO. 2022. "Improving the Quality of Care for Maternal, Newborn and Child Health." Geneva. improvements in nutrition, health care provider WHO/UNICEF (World Health Organization/United Nations Children's Fund). 2019. “Survive and competency, positive user experiences, equity of care, and Thrive: Transforming Care for Every Small and Sick Newborn." Geneva. economic benefits (Kruk et al. 2018). World Bank. 2018. "Is Indonesia Ready to Serve ? An Analysis of Indonesia’s Primary Health Care Conduct implementation research to investigate ways Supply Side Readiness." Washington, DC. to strengthen community-level decision making and World Bank. 2020. "Spending Better to Reduce Stunting in Indonesia: Findings from a Public accountability processes to encourage the demand for Expenditure Review [Internet]." Washington, DC. quality services and enhance program course corrections (Subandoro, Holschneider, and Ruel-Bergeron 2021). This HNP Knowledge Note highlights many of the key findings from two recently published World Bank and GFF reports: Improving the Quality of Frontline Nutrition Services Inin Indonesia's Health Sector (2021) and Operationalizing Multisectoral Nutrition Programs to Accelerate Progress: A References Nutrition Governance Perspective (2021) Acosta, A., and J. Fanzo. 2012. "Fighting Maternal and Child Malnutrition: Analysing the Political and Institutional Determinants of Delivering a National Multisectoral Response in Six Countries. A Synthesis paper.” Brighton, UK: Department for International Development. Billah, S. M., N. B. Ali, A. N. S. Khan, C. Raynes-Greenow, P. J. Kelly, M. S. Siraj, S. Askari et al. 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