Hospital Padrino

Reducing the maternal mortality ratio (MMR) is a global health priority aligned with the Sustainable Development Goals and represents an indicator of a country's level of development. Despite the efforts, the expected goals have not yet been achieved, especially after the effects of the Covid 19 pandemic in low- and middle-income countries (LMIC). In 2020, an estimated 287,000 women worldwide died from maternal causes, equivalent to almost 800 maternal deaths every day and approximately one every two minutes. The global MMR was 223 maternal deaths per 100,000 live births, with the worst indicators in low- and middle-income countries (LMIC). In these scenarios, fifty women experience extreme maternal morbidity (EMM) for each maternal death, and 8% of hospital deliveries have complications.

Colombia is no stranger to this problem. In epidemiological week 52 of 2021, the National Institute of Health reported 661 maternal deaths; 485 corresponded to early maternal mortality (occurring during pregnancy, childbirth, and up to 42 days after the end of gestation), 134 late (happening from day 43 up to one year after the end of pregnancy) and 42 due to coincidental causes (external cause lesions), which represented an increase of 24.1% in early MM compared to 2020, with an RMM of 78 deaths per 100,000 LW for the country, increasing to levels reached 12 years ago.

The department of Valle del Cauca was established in the Valle Invincible Development Plan 2020 – 2023 to maintain the early MMR at less than 25 per 100,000 live births. The department is defined in Colombia as one of the territories with the largest number of services enabled for obstetric care (figure 4) and with a network that allows average access to highly complex obstetric services for the resolution of emerging problems, being greater the difficulties in the north node of the department where these distances exceed 200 kilometers. However, the trend of excessive maternal mortality and morbidity in the department has exceeded the expected goals, especially as of 2019. The COVID-19 pandemic exacerbated the upward trend in MMR since it limited the opportunity and access to prenatal check-ups and follow-ups for pregnant women, decreased the possibility of detecting treatable diseases during pregnancy promptly, and prevented fatal outcomes. The RMM for the year 2021 for the department of Valle del Cauca department was still above the national average, 78.6 per 100 NV. Critical determinants of this behavior are access barriers in low/medium complexity hospitals and health workers' challenges in providing adequate obstetric care. They must strengthen their skills and have effective management networks for pregnant women.

The Strategies to End Preventable Maternal Mortality (EPMM) of the World Health Organization (WHO) establish that each region and, in the case of Colombia, each department needs tools to determine priorities based on the direct causes and the most frequent determinants of MM in the respective contexts. In this way, effective care for pregnant women must be based on intersectoral collaboration and cooperation, adapting to circumstances, positive aspects, and local difficulties at all levels.

The Hospital Padrino Strategy of Fundación Valle del Lili, Cali - Colombia, is a model of social innovation in health aimed at vulnerable populations in Colombia who also have a greater health risk, as is the case of the obstetric population. In this sense, Hospital Padrino seeks to contribute to equity in health care, timely access to quality health services, the promotion of knowledge, and the strengthening of physical infrastructure, with the ultimate purpose of reducing preventable deaths and providing a chance of life for the entire population.

Hospital Padrino is a model of collaborative work between hospitals, where a public or private hospital of high complexity and quality (Hospital Padrino) within the conditions of the territory accompanies and supports providers of less scope (sponsored Hospital) to improve quality, timeliness, and resolution of care, under the coordination of the national, regional and local government. We seek to reduce avoidable maternal mortality as a strategy aimed at the obstetric population.

Through education strategies that save lives, it is intended to strengthen the knowledge and skills of the health teams of sponsored hospitals with workshops that combine the theoretical and the practical, emphasizing the development of soft skills for teamwork and humanization. of attention. In addition, the model strengthens Telehealth in the territory by directly improving the care conditions of users with the use of telemedicine or telecare strategies from the Padrino Hospital, allowing patients and pregnant women from sponsored hospitals to access specialized attention and achieve less time in their diagnoses and management.

Hospital Padrino supports the premise of decent hospitals for equitable care, supporting sponsored hospitals in adapting the hospital infrastructure to offer services under the best standards and humanization, emphasizing obstetric care. In this way, under the leadership and in alliance with the government, health institutions from low to high complexity form integrated networks of hospitals that allow better communication and care between the hospitals of the model.

To form the network between Hospitales Padrino and sponsored hospitals, hospitals are selected with criteria that ensure that the benefit is focused on the most vulnerable population and institutions with the greatest need for improvement. The strategy's success is to adapt the model to the needs of the services and to carry out sponsorship respecting the networks of providers in the intervention area, recognizing the functioning of the country's health system. In this way, all hospitals are articulated from low to high complexity, expanding and strengthening public and private alliances in the region where the intervention is being carried out, always with government support.

To the extent that these objectives are achieved, Hospital Padrino seeks to significantly reduce maternal and perinatal mortality in the intervention areas, in precise alignment with compliance with the country's Sustainable Development Goals.

Hospital Padrino benefits four population groups:

1. To the patients and their families who are the focus of the intervention,
2. Medical and non-medical personnel that make up the human resources of the sponsored hospitals 
3. Health provider institutions that have accepted participation in the strategy 
4. Municipal and departmental health secretaries and the Ministry of Health and Social Protection (MHSP) of Colombia

The first intervention region was the Department of Cauca, which has presented poor maternal and perinatal health indicators. These results are related to poor access by the rural population to health services, poverty rates, armed conflict, and lack of adherence to primary care programs by indigenous communities. For this reason, in 2018, the Fundacion Valle del Lili (FVL) implemented Hospital Padrino's fourteen level I and II hospitals. This project has made it possible to statistically and significantly reduce perinatal mortality, extreme maternal morbidity, and the disease burden of pregnant women cared for until 2023 (Escobar MF et al. Digit Health.2022 Oct 2;8:20552076221129077; BMC Pregnancy Childbirth.2022 Jul 29;22(1):604). 

Since then, Hospital Padrino has extended the scope of its activities to 123 hospitals in the region. In the department of Valle del Cauca during the years 2021 and 2022, Hospital Padrino held 51 workshops with the assistance of 980 gynecologists, general practitioners, nurses, and nursing assistants. An improvement of 64% was found in hospital conditions for pregnant women's care; 1250 women in obstetric emergencies were cared for through telehealth systems, and none died. From 41 cases of maternal mortality treated in 2021, it was possible to reduce to two cases by the end of 2022, with an RMM of 12.0 cases per 100,000 NB. According to the National Institute of Health of Colombia report, by 2022, a significant reduction in early maternal mortality in the country will be observed.

In the department of Cauca, 30 workshops have been held to cover 44 obstetric care institutions and have allowed the timely transfer of 500 pregnant women in critical conditions. A particular emphasis is placed on Timbiquí and Lopez de Mickay due to difficult access conditions and the high extreme poverty rate. Hospital Padrino has made it possible to bring maternal mortality to zero in the year 2023.

In the department of Nariño, the project has focused on the Pacific region, and 40 pregnant women in critical conditions have been mobilized from areas with abysmal human development indicators.

In 2023, the MHSP of Colombia established the Plan for the Acceleration of the Reduction of Maternal Mortality, whose line of action 4 aims to develop and strengthen technical capacities for the management and care of obstetric emergencies and newborn complications using the Hospital Padrino initiative. This project was prioritized for implementation in 14 territories in a collaborative alliance with the FVL, the Colombian Federation of Gynecology and Obstetrics, the National University of Colombia, the Pan-American Health Organization, and the World Bank. The project began in May 2023 with the sponsor hospitals of Valle del Cauca, Cauca, Nariño, Cesar, and Magdalena.

Our team is the right one to carry out the Hospital Padrino strategy because it has seen first-hand the suffering and ravages of maternal mortality. Fundación Valle del Lili is a level IV institution in southwest Colombia with the largest obstetric critical care unit in the country, which has cared for more than 50,000 obstetric patients. However, the history of Hospital Padrino began in 2018 because two obstetric gynecologists must witness the death of an indigenous woman in her eighth pregnancy at the door of the institution: she did not receive the minimum treatment indicated, and she was transferred in the worst conditions, accompanied by her seven children. 

This case generated a substantial emotional impact on the FVL team and awoke the need to move Hospital Padrino to all hospitals where it is more challenging to maintain education, the population has more outstanding violations, and maternal mortality is concentrated. For this to be a reality, it was necessary to carry out a consistent approach with the governments to jointly understand the health and social determinants explaining each territory's health results. This solid alliance has been definitive because Hospital Padrino's basis is to follow government policies and help cover the needs that the state cannot or does not cover.

The main strength of Hospital Padrino is that in articulating a network of 123 hospitals, it has had to go and get to know each hospital, review the conditions of care in each service and co-create with the workers plans to improve conditions. Each hospital's strategy's success lies in its organizational commitment and governance for implementing the process. However, success depends on the adoption and affection that hospital workers feel for this model. For this reason, a large part of the process that Hospital Padrino develops is to generate empathy between the teams, strengthen the bonds of trust, and always support them in their difficult moments. 

In some territories, it has been necessary to approach traditional midwifery communities and indigenous councils. Due to the influence and respect for their traditions, we have had to exchange knowledge, undergo rites and testify before the traditional rulers, our Hospital Padrino. Only with permission and authorization have we been able, for example, to work hand in hand with the Mizak community in Silvia, Cauca. 

We have started conversations and focus groups with the community of pregnant patients. The most dramatic of these meetings was held with the community of 42 pregnant patients from Barbacoas, Nariño. This area has a component of gender violence due to illegal mining and armed conflict. The heartbreaking testimonies of patients have motivated us to train hospital teams in humanization, patient-centered care, and delivery care with a differential approach, favoring diversity, equity, and inclusion.

Since 2021, we have shifted the strategy's focus from providing a service to the concept of social innovation in health. For this, the project leaders needed to be trained in a master's degree in management for social innovation at Icesi University.

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Our solution currently serves the following:

• 123 hospitals in the Pacific region and the departments of Valle del Cauca, Cauca, and Nariño. Throughout 2023, we plan to reach 140 hospitals in total
• 3,600 health workers, including general practitioners, medical specialists, nurses, and nursing assistants
• In these territories, the target population is 7,600,000 people. At this time and for this call, we have focused our proposal on obstetric care and the reduction of perinatal mortality, but at the same time, Hospital Padrino works on programs in other specialties: neonatology, pediatrics, adult emergencies, traumatology, neurology, cardiology, nephrology, and psychiatry
• In the Hospital Padrino Colombia project, we must end the year 2023 with the training of 21 sponsoring hospitals and continue with 105 sponsored hospitals, which provide coverage to approximately 10 million women of childbearing age. This project is in progress.

We are applying a Solve for the following reasons:

• Sustainability mechanisms: We want to explore alliances that allow us to know, learn and evaluate sustainability mechanisms of the strategy from the point of view of social innovation in health.
• Monitoring, follow-up, and impact measurement systems: we have little development in advanced data monitoring and follow-up systems of as much scope as the ones we are now managing, for which we consider that there is a learning opportunity or we can become an attractive project in this area for expert academic groups in these areas.
• Technological developments: Our entire telehealth model now depends on an in-house product that is a technological platform for digital inter-consultation between the Padrino Hospital and the sponsored hospitals. In addition, much of the communication with hospitals is done through WhatsApp because it is widely accepted among Colombians. However, we believe we can learn about new telehealth models, especially now with the development of artificial intelligence.
• Virtual educational model: For now, the entire educational process we are carrying out and the scholarly communication with the hospitals is through WhatsApp. We must build a virtual education platform that hospital staff can access and support similar projects in Latin America.
• Visibility of the strategy: We believe it will allow us to make ourselves known in academic and world scenarios where we are just learning to make our work visible. Our Global Health Equity unit's basic principles are global health and social innovation in health. It is very young (less than six months old), and we need to learn and know strategies to make ourselves visible and generate alliances with similar programs worldwide.
• Financial funds: As a strategy that has been 70% self-financed by the Valle del Lili Foundation, we depend on alliances with donors from different areas that support our work to grow and increase our coverage. 

Hospital Padrino is an innovative strategy from different perspectives:

• Social innovation in health: believes that Hospital Padrino tries to solve a significant social problem in health in our country, which is inequity in access and the lack of quality and safety in obstetric care in the territory. As a model of social innovation, it has brought together in a single model the educational processes in the adult population that are effective for change in action, it has managed the appropriation of technology quickly and sustainably, and it has organized a reference and counter-reference model. of patients between hospitals of different levels, without spending on higher expenses for sponsored hospitals
• Use of telehealth: telehealth technologies in our country before the pandemic was very low, even though Colombia has laws that allow its implementation and growth. However, even after Covid 19, there is a lot of fear on the part of medical teams about adopting technology. For this reason, Hospital Padrino has financed the creation of formal digital inter-consultation systems and has used the most significant mobile application in the country to generate communication channels. Again, trying to minimize the investments of the territory because the Colombian health system has serious financing problems.
• Creation of compelling and interconnected networks of hospitals: The models of interconnected networks have strong evidence for their implementation. However, there are few examples of this impact at the level of Latin America. The possibility of effectively connecting these 123 hospitals, creating bonds of trust, and generating many requests from other hospitals has developed an innovative model for Colombia that can be consolidated as a public policy.
• Linking traditional medicine: within the process of positioning Hospital Padrino as an effective strategy for all health actors, we believe that being able to work effectively with ancestral medicine communities is a milestone for Western medicine in the country, and It constitutes an innovative example of how by linking and recognizing the role of all actors, strategies that save lives are effective.

The impact indicators we aim to achieve in the next five years are public health and strategy indicators.

Public health indicators

• Significant and sustained reduction of avoidable maternal mortality in the intervention territories. Due to the country's inequity of quality health coverage, it is impossible to define a single goal for all regions.
• Significant and sustained reduction of extreme maternal morbidity, as the primary marker of maternal health, in the intervention territories.
• Significant and sustained reduction in perinatal mortality in the intervention territories.
• With the Colombia maternal health project, the achievement of the maternal mortality ratio of 30 per 100 ml of live births for the country before the year 2030.
• For projects in other specialties, the significant reduction in avoidable mortality and morbidity is by the national goals established for each thing.
• Measurement of cost-effectiveness and social return through the unlocked value of the Hospital Padrino strategy with reducing maternal mortality.
• Measurement of cost-effectiveness and social return through the unlocked value of the Hospital Padrino strategy with the reduction of avoidable non-obstetric mortality in the territory.

Indicators of the Hospital Padrino Strategy

• Increased strategy coverage in the Colombian and Latin American territory, with expansion and adaptation of the model according to the region's needs. For Colombia, we hope to be in at least 50% of the country's departments with the maternal health project, which has been the pioneer and has a long track record in implementation.
• Increase in the areas of intervention in medicine, with particular emphasis on pathology programs whose fatal results are highly adjustable if there are precise and rapid interventions. Such is the case of stroke, infant mortality, trauma mortality, acute myocardial infarction, etc.
• Increase and strengthen the primary health care strategy. Starting in 2023, the Padrino Hospital has started programs with a maximum of 42 hospitals for managing chronic hypertension and modifying cardiovascular risk in high-risk populations. Starting in the second semester of 2023, Hospital Padrino will begin to manage processes for the early detection and timely management of cancer in the population of sponsored hospitals. After five years, these projects must be consolidated and represent impact indicators that verify that Hospital Padrino is a strategy aligned to the continuum of primary health care.
• Increase in the number of collaborative alliances with international cooperation agencies, non-governmental organizations, universities, and other actors that can support the growth of Hospital Padrino (and its scope).
• Belonging to social innovation networks in health and global health that work on similar projects, where Hospital Padrino is also a global leader that strengthens other initiatives.

The indicators we are measuring are general to the strategy and indicators of each project and specific to this area in the case of the maternal health project.

General indicators of the strategy:

• Replication of the strategy in new hospitals and identified territories measured through the number of sponsored hospitals.
• Hospital Padrino projects for each item of Development Goal 3, measured as the number of projects for each goal of SDG 3
• Compliance with the budget of the Padrino Hospital projects, measured as the percentage of compliance with the general budget of the strategy.
• Global results of the projects of the Hospital Padrino strategy: percentage of compliance with the monitoring indicators of each project.
• Dissemination of the activities of the Padrino Hospital: Number of activities to disseminate the strategy

General indicators of each project

• Coverage of the project in the defined territory: the number of sponsored hospitals that attend the educational strategies agreed upon in each project.
• Results of pre and post-tests carried out in each educational event.
• Results of the satisfaction survey of those attending academic events.
• Number of telehealth events of the sponsored hospitals of each project.
• Percentage of patients referred through the Hospital sponsor strategy
• Percentage of patients treated in follow-up seven days after the care event.
• Epidemiological characterization of the patients attended by telehealth

Maternal health indicators

• Percentage of compliance with implementing intervention packages for emergency obstetric care.
• Extreme maternal morbidity ratio in the territory of implementation
• Maternal mortality ratio in the territory of implementation
• Perinatal mortality ratio in the territory of implementation
• Value unlocked in dollars with the reduction of avoidable maternal mortality
• Qualitative evaluation of the perception of health workers of the Hospital Padrino strategy with focus group methodology, designed by the Yunuz Center of the Icesi University of Cali, Colombia.

Theory of change in maternal health- Hospital Padrino

Problem to solve

Reduce the avoidable maternal mortality ratio in the implementation territories

Objective

Supplies

Activities

Outcomes

Short term outcomes

Long term outcomes

Strengthen the competencies of health human resources for quality clinical care

AND

Promote and improve adherence to educational programs based on the best available evidence.

A medical group in charge of the educational process

Specialized and expert clinical staff.

Basic information on health care, risk groups, and installed capacity.

Protocols/guidelines/bundles based on scientific evidence.

Audiovisual support elements.

Financial resources.

Diagnose and prioritize health needs and institutional capacities with the methodology of intervention packages.

Define training topics in co-creation with hospital staff.

Plan workshops and educational processes with health secretaries

Develop educational workshops with theoretical and practical component.

Evaluate the knowledge and satisfaction of attendees.

Theoretical-practical training workshops for health personnel on prioritized events.

Better knowledge and adherence to evidence-based clinical guidelines and protocols

Better resolution at the primary-secondary levels of care (less referral to high complexity).

Sustained reduction in maternal mortality, extreme maternal morbidity, and perinatal mortality

Promote and improve communication between hospitals to provide coordinated clinical care

AND

Increase access to medical care with equity for the most vulnerable population.

Specialized and expert clinical staff to respond to interconsultations and telecare

Licenses for technological platforms (Liliconnet and Microsoft Teams).

Regulations and criteria for service authorization.

Educational support material for telehealth use.

Financial resources

Internet availability

Diagnose the capacity of telecommunication networks.

Accompany the administrative process to comply with qualification criteria.

Train in the adoption of ICTs for health care.

Set up a telehealth care route.

Manage care with complementary networks.

Telehealth network formed.

Care by synchronous tele-expertise or teleguidance with sponsored hospitals.

Activation of telehealth in cases of priority events: increase in patients treated through telehealth

Better resolution at the primary-secondary levels of care (less referral to high complexity).

Sustained reduction in maternal mortality, extreme maternal morbidity, and perinatal mortality

The core technologies that power our solution are those that support the following:

• Telehealth processes with robust platforms that can handle a high number of patients and allow the registration of formal interconsultations paid for in the health system and teleassistance that are not charged but are valid. At this time, for example, we only have a basic dashboard for recording tele-assistances.
• The use of artificial intelligence to create educational systems and applications that make it possible to generate solutions for the medical group in front of the patient. For example, the generation of an application that consolidates clinical patient data, data from early warning systems, and taught protocols can easily guide clinicians on the priority management strategy and level of care
• Interactive, friendly, easily accessible educational platform with up-to-date information that allows the development of tele-education strategies for specialists, general practitioners, nursing assistants, and nurses from sponsored hospitals.

The Fundacion Valle del Lili, as the managing institution of Hospital Padrino, has developed a substantial movement in the last two years to incorporate the concepts of diversity, equity, and inclusion in patient-centered care and the training of all hospital workers. At this time, we have a clear policy of differential approach for the attention of our users, and the implementation of a tactical plan for equity, diversity, and inclusion of all clinic workers began. For this reason, we are implementing the inclusive route with the support of the Canadian organization Cuso International. A leading group of 25 people is being formed in courses on gender, disability, the LGBTIQ+ population, the migrant population, etc.
Additionally, within the strategy, the leaders have been officially trained in social innovation in health and have attended events on this topic required by the government of each of the territories. Within the Hospital Padrino team, we constantly work on understanding diversity, equity, and inclusion as the compass that guides the project. We have members of the LGBTIQ+ community, we have a majority of women, including management positions, and we have no restrictions of any kind for the entry of our collaborators.

Type of interventions

Collaborative work where a hospital of high complexity and quality supports providers of lesser scope 

Value proposition

• Medical care for pregnant women in emergencies that require high-quality care, safety, humanization, and coordination between hospitals of different levels of complexity to reduce avoidable mortality.
• Network of hospitals integrated and aligned from the theoretical point of view and processes for the management by levels of patients in obstetric emergencies.
• Joint work of the community, the medical community, companies, agencies, and the government to ensure care with humanization and empathy for patients.
• Maternal mortality ratio
• Coverage and Impact of educational workshops
• Coverage and Effectiveness of the telecare network

Impact measures:

Key activities

• Theoretical-practical training workshops for health personnel on prioritized events.
• Care by synchronous tele-expertise or teleguidance with sponsored hospitals.
• Coordination between levels of care and the regional health secretaries

Key resources

• Fundación Valle del Lili 
• Brand
• Human resources of Hospital Padrino
• Technological resources
• Donor network

Partners and stakeholders

• Ministry of Health, municipal or departmental health secretaries
• National or international cooperation agencies
• National or international scientific societies
• Associations, unions, or foundations that work for women and their children.
• Private businesses
• Community-based associations or foundations
• Medical group and hospital leaders for the strategy's adoption process (including the technological one).
• Community leaders: If the community feels involved, understands the model, and can provide feedback on the project, they will be in charge of maintaining the strategy and motivating it to be carried out.

Segments

Territorial segments

• To the patients and their families who are the focus of the intervention,
• Municipal and departmental health secretaries and the Ministry of Health and Social Protection (MHSP) of Colombia
• Medical and non-medical personnel that make up the human resources of the sponsored hospitals 
• Health provider institutions that have accepted participation in the strategy

Organizational segments

Customers

• Health secretaries and the Ministry of Health
• Donors
• Health provider institutions 

Channels

·       WhatsApp

·       Platforms: Lili connect

·       Microsoft Teams

·       Social media network 

·       Hospitals of low and medium complexity

·       Government calls

Cost structure 

• Staff 
• Online platfoms
• Medical fees expenses
• Logistics expenses

Surplus

• Does not apply. The strategy does not leave profitability, because at this moment everything is reinvested in the same strategy.

Revenue Donations

For Hospital Padrino to be financially sustainable, we have considered the following options:

1. Sustained subsidy of the strategy by the Fundación Valle del Lili from its area of social responsibility, since the Foundation, being a non-profit institution, must reinvest the profits from the business in social responsibility and education programs.

2. Donations to the strategy from the private company under concepts of social responsibility and shared value.

3. Sale of social innovation projects in health to international and national cooperation agencies, non-governmental organizations, and local and regional health departments.

4. Application to research calls with the Colombian Ministry of Science and Technology in areas of public health and social innovation in health

5. Application to grants and calls that may include research projects on social innovation networks in health and global health

6. Creation and generation in Colombia of new sources of financing, such as impact bonds, which at this time have only been used in employability projects in the country.

7. Creation of Hospital Padrino as a sustainable business whose investment is 100% re-investable in the sustainability of the strategy. This projection is under review

To sustain the strategy since 2022, these have been the contributions received:

Donor

Value in dollars

Fundación Valle del Lili 

$ 260.254

Ministerio de Ciencias y Tecnologías de Colombia

$ 147.777

Secretaria de Salud del Valle del Cauca

$ 128.888

Secretaria de Salud del Cauca

$ 4.444

Instituto departamental de salud de Nariño

$ 8.888

USAID

$ 58.977

Organización internacional para las migraciones 

$ 26.666

Abbott

$ 11.555

J&J

$ 24.000

Propacifico

$ 2.222

Total

$663.671