The overall process of QS development

The development of QS should be a participatory and multidisciplinary exercise involving policy-makers and relevant stakeholders. It involves several stages including convening QS committee, selecting topic areas, defining the scope, selecting source documents, identifying relevant recommendations, prioritising recommendations, devising statements and measures, conducting budget impact analysis, convening a consultation with interested parties and present the final QS to the committee.2 In Thailand, the development process was informed by a guideline for developing QS in low- and middle-income countries and adapted to the country’s context. A technical working group was set up comprising a chair and topic experts, for example, doctors, nurses, academics and policy-makers; HITAP was the secretariat of this working group.

Topic prioritisation and selection

The priority setting process of topic areas in P&P was carried out in five steps (figure 1). Table 1 summarises the roles and composition of all consultation groups involved in the prioritisation process. Since QS development is new to Thailand, the first step consisted of using the availability of QS in other countries and the readiness of the Thai health database as two inclusion criteria to shortlist services. The examples of QS obtained from other countries were important because they served as prototypes for this development. Additionally, the accuracy and completeness of data within the database were also crucial for measuring the progress and outcomes of the services provided. The P&P services in the benefit package were categorised into five categories per beneficiaries’ groups. In total, 83 services were included and each service in the benefit package was reviewed against these two criteria. Table 2 presents the 21 services for all five categories that met the inclusion criteria.

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Figure 1

Selection process of topics for quality standards development. Topics were selected through an iterative process. The first group of stakeholders were gathered to agree on criteria and select ANC as a priority area. The second group of stakeholders were invited to participate in a focus group discussion for the topic engagement process. The working group finalised the prioritised ANC problems for quality standards development. ANC, antenatal care; HITAP, Health Intervention and Technology Assessment  Program.

Subsequently, inputs for proposing the criteria to further narrow down the choice of services were determined. The research team reviewed international literature to find criteria used in setting the priority of topics for developing QS or related initiatives. The review focused on literature indicating criteria for setting the priority of interventions to improve quality of care as well as existing criteria for the development of the Thai benefit package. The NICE QS guideline recommended: (1) size of problems; (2) having a high impact on patient safety; (3) having a high-cost impact or high resource use and (4) current variations in service delivery or access to services as the criteria.18 19 Furthermore, a study using multiple criteria decision analysis to prioritise topics for health technology assessment for the development of the universal health coverage benefit package in Thailand recommended: (1) size of population affected by disease or health problem; (2) severity of disease; (3) variations in practice; (4) the effectiveness of health intervention; (5) economic impact on household expenditure and (6) equity and social implications as the criteria.20 Variations in service delivery or access to services were also suggested by a study on identifying topics for health technology assessment in Thailand and by the Agency for Healthcare Research and Quality.

From these findings, a set of appropriate and feasible criteria in the Thai context was then drafted by the research team. The criteria included: (1) size of the population affected by disease or health problem; (2) coverage of P&P services; (3) quality of service provision; (4) variations in service delivery or access to services and (5) effectiveness of health intervention. These criteria were proposed with scores ranging from 1 to 5 for each criterion.

Next, stakeholders were invited to a consultation meeting which convened in August 2017 to comment on the proposed criteria. As recommended in the guideline,2 stakeholders comprising policy-makers, healthcare practitioners, academics, service users, patient groups and members of civil society discussed the feasibility and appropriateness of the selected criteria. The composition of stakeholders is presented in table 1. These stakeholders were important in the implementation of P&P programme either making-decision and plan, delivering services, quality assurance or monitoring and evaluation. Moreover, service users, patient groups and members of civil society could offer insight into the challenges and obstacles of receiving P&P services. During the discussion, the following changes were suggested:

Criterion 1: Stakeholders commented that the size of the population affected by disease or health problem was not appropriate because it might overlook some health conditions that are less prevalent but have high severity, for example, rare diseases. Therefore, the burden of disease in terms of the loss of Disability-Adjusted Life Years (DALYs) seemed to be a better criterion to compare the effects of disease on the population. However, some concerns were raised on the availability of information for all diseases and health risks.

Criterion 2: Stakeholders did not agree with the second criterion as they viewed that the coverage of services depended on various factors other than the quality of healthcare provision. For example, a low uptake of diabetes screening may be the result of low risk perceived by service recipients or travel/transport issues to health facilities for people who reside in mountainous areas. As such, having QS would still not solve these issues. In addition, stakeholders pointed out that the second criterion was similar to the fourth criterion, that is, the variation of service delivery or accessibility, which might lead to double counting if these two are used together.

Criterion 3: Stakeholders agreed that the third criterion was important for this project but raised concerns on how to measure the quality of services provided because studies exploring the quality of P&P services were limited.

Criterion 4: Stakeholders agreed with this criterion and suggested removing variation in the services covered by the benefit package of the three health insurance schemes (the Universal Coverage Scheme, the Social Security Scheme and the Civil Servant Medical Benefit Scheme) since they use the same benefit package for P&P services. The criterion should instead focus on the variation in access to services across different subpopulations or geographical areas and the variation in providing such services.

Criterion 5: Stakeholders suggested to remove the fifth criterion on the effectiveness of health intervention because this criterion was already used during the development of benefit package of P&P services.

In addition to the proposed criteria, stakeholders raised concerns about the scoring algorithm as they anticipated that reliable data for each criterion may not be available for all services, resulting in low scores for those services. This may create biases in the priority setting results.

Given that the proposed criteria were deemed unready to be selected in this round coupled with the time constraint, a consensus-based approach was suggested to choose topics for further review. Problems around service delivery of the services in table 2 were discussed by stakeholders, and the antenatal care (ANC) package was ultimately selected. This was chosen as a priority area because ANC services still need to be improved as evidenced by two important national health indicators including the coverage of ANC uptake by pregnant women before the gestational age of twelve weeks (59% in 2016); similarly, only 26% of pregnant women with low risk pregnancies availed of ANC services at least five times in 2016.21 Furthermore, stakeholders suggested that the effectiveness of QS needed to be evaluated to inform policy-makers of its potential in improving quality of care in Thailand before expanding QS to other areas. Following this suggestion, ANC was deemed as the most suitable service because health outcomes from better ANC can be seen on a short-term basis.

Therefore, the team revisited the criteria based on stakeholders’ comments and proposed to use the revised version for the next round of priority setting. The revised criteria included: (1) current quality of service provision in Thailand by considering the readiness of infrastructure and human resources, process of care and health outcomes; (2) burden of disease as measured in terms of loss of DALY; (3) variation in service delivery and uptake across subpopulations or geographical areas and (4) availability of domestic or international guidelines and recommendations. The first three criteria attempt to explain why quality improvement is needed based on the current situation, and the fourth criterion indicates the feasibility of developing QS based on high-quality evidence. Concerning the availability of reliable information about DALY loss, and data on some process of care and health outcomes, for example, postnatal care, screening for mental illnesses, screening for tobacco use and alcohol use disorders, it was not feasible to score the service against each criterion at that time. Therefore, the team proposed to consider the criteria as a starting point for discussion and allow for deliberation to identify priority topics. Table 3 illustrates the revised criteria and their definitions as suggested by the consultation with key stakeholders.

Topic engagement: identifying areas for quality improvement

Topic engagement is a process that aims to identify areas for quality improvement and highlight emerging areas of practice within the selected topic areas. Document reviews were undertaken initially to understand the current situation of ANC services in Thailand and its barriers from both providers’ and clients’ perspectives. This process was followed by two focus group discussions in September 2017 among stakeholders who have been working in the area of maternal and child care. The first group consisted of policy-makers, academics and healthcare providers in referral hospitals. The second group consisted of healthcare providers from district and health-promoting hospitals, health volunteers and a pregnant woman.

Discussions were guided by open-ended questions as informed by the review. The first group discussed issues related to service provision, administration, logistics and communication about ANC services. The second group focused on service provision, service utilisation and barriers to access.

Important issues in ANC services from the perspective of service providers and service recipients were summarised as follows:

1. Pregnant women were not concerned about or did not perceive the benefits of receiving ANC services within 12 weeks of their gestational age. They also reported a lack of proper information about ANC services.

2. Health practitioners reported that they used different practices in measuring the fundal height of pregnant women.

3. Pregnant women reported inadequate laboratory examinations, for example, complete blood count test, the tests for syphilis and HIV among couples of pregnant women and lack of information about the services and results of the examination. On the other hand, health practitioners indicated that the follow-up system for patients who had undergone an examination was inadequate.

4. It was observed that not all pregnant women received triferdine (iron+folic acid+iodine) supplements throughout their gestation periods even though Thai guidelines recommend triferdine for the entire pregnancy period.22

5. Health practitioners reported that non-standardised screening programmes for pregnancy-induced hypertension, preterm labour and gestational diabetes were delivered across the country. Additionally, there were also insufficient emergency referral services.

6. Health practitioners reported time constraints of staff and parents for attending parental schooling, lack of well-trained staff to provide services and lack of standard guidelines for service arrangements. This resulted in variation in providing parental schooling across different geographical areas.

All six issues were perceived as priority areas for improving quality of care. However, given the capacity of the research team and the availability of resources and time, developing QS was possible in only three areas. Therefore, these six issues needed to be prioritised again using the agreed-on criteria as described earlier. The prioritisation process in this stage was conducted by a technical working group comprising experts and representatives from policy-making bodies related to ANC programmes (table 1).

The technical working group suggested that this project should focus on important maternal and child health issues rather than focusing on a single intervention which may not be effective in reducing the burden of the problems; therefore, a package of interventions to mitigate the problems should be formulated. Following this approach, information related to the six issues were discussed. The group finally reached a consensus on selecting the topics of preterm labour, pre-eclampsia and postpartum haemorrhage for developing the first set of QS. These topics were selected for the following reasons:

1. The three conditions had the high burden of disease as indicated by the DALYs loss of 70 928 DALYs for preterm labour, 1346 DALYs for pre-eclampsia and 1318 DALYs for postpartum haemorrhage.23

2. The conditions were prevalent among pregnant women in Thailand—preterm birth rate was 12 per 100 births,24 25 the prevalence of pre-eclampsia was 5%–6%26 and postpartum haemorrhage was the cause of 184 maternal deaths from 2011 to 2015.27

3. These conditions were important problems that led to relatively high mortality and morbidity in mothers and children.27

4. Variation in the practices and service uptake were not documented but informed by the expert and local practitioner experiences.

Besides the criteria proposed, members of the working groups noted that interventions to tackle these issues already existed and could be carried out by healthcare providers at the primary care level.