MRC CONFAP Newton Strengthening the health system in Brazil: Improving maternal and child health services during the first 1000 days through community engagement and social accountability

The quality of healthcare available to women and children within the first 1000 days of life (from conception until about 2 years of age) in Brazil is highly variable, despite policies for improvement. This has led to higher maternal mortality and morbidity than may be expected in a country such as Brazil. This project, EU QUERO (meaning 'I want' in Portuguese), is testing whether an intervention to improve the quality of care is feasible to conduct as well as indicating whether it is likely to be successful. This will be conducted in two states of Brazil, Goiás and Maranhão, both of which have poorer maternal health than expected. Prior to the intervention, a period of assessment of current quality will be conducted using two datasets that have already been collected. Results from this analysis will be mapped using the latest techniques so that hotspots of good or bad quality healthcare can be identified. This will inform the areas selected for the intervention. The EU QUERO intervention is implemented within Basic Health Units (the smallest level of the health system organisation) and encompasses two different elements. The first is to make mothers and the wider community more aware of the current quality of care available to them at different points within the first 1000 days of life - during pregnancy, during delivery, in the immediate post-delivery period and with regard to the child's health. This will be conducted by the development of facility level quality scorecards which will highlight the good and poor aspects of healthcare to users. The scorecards will list the four different phases within the 1000 days and rate the services available to the mother within each phases, with the best quality services receiving a 'Diamond' rating, while the poorest will receive a 'Bronze' rating. Previous research indicates that knowledge of these aspects improves quality through greater transparency of the health system, while health workers also understand the aspects where they are not performing and make a concerted effort to improve. The second element of the intervention is through the delivery of rights-based education to mothers. This will include knowledge about individual rights to health care, including highlighting what an individual should be entitled to and the quality that should be expected. This has been seen to empower mothers who will then be encouraged to demand more of the health providers, again improving quality of care. EU QUERO will develop these scorecards and rights based education materials to disseminate within selected Basic Health Units and, following this happening, assess if this is a feasible intervention to conduct at a wider scale. Improvements in quality will be assessed through the development of new quality scorecards, which will indicate what has been improved and whether any improvements have occurred evenly over the 1000 days period under study. Quality will also be assessed through looking at health outcomes, such as whether mothers received adequate antenatal care or whether the child received vaccinations in a timely fashion. A further aspect is an explicit focus on ensuring that adolescent voices are heard throughout the intervention and evaluation. The project is conducted in collaboration with the state Ministries of Health and hence the successful implementation of the intervention will inform future strategies to improve healthcare for mothers and children. It will also engage mothers, communities, health workers and policymakers throughout the period of implementation, with the actual intervention co-created between the project team and these stakeholders, so the material presented to mothers is relevant and understandable. The intervention will be assessed for scalability within Brazil and in other countries, with mothers facilitated to demand the best quality care available, strengthening the health system as it responds to these demands.