Improving health-care quality in resource-poor settings

Improvements in health-care quality can contribute to healthier populations. However, many global and national health strategies are not sufficiently considering the issues of measuring and improving health-care quality in low-resource settings. (1) The barriers to delivering high-quality care are often similar across different health systems. However, the extent and mechanisms through which these barriers affect quality improvement interventions may be different in resource-poor settings. (2) Investments in health systems strengthening without continuous quality improvement is thought to be a useless effort. (3) Conversely, only focusing on quality improvement in a resource-poor context without engaging the broader health system for support is of limited value. Hence, both areas must be improved simultaneously. Here, we call for renewed focus on quality improvement of health-system delivery by policy-makers, managers and health-care providers, working at all levels of health-care systems in resource-poor settings. To maximize the potential of quality improvements, we propose an approach focusing on five elements: (i) systems thinking; (ii) stakeholders' participation; (iii) accountability; (iv) evidence-based interventions; and (v) innovative evaluation (Box 1). Some of the elements are well supported by peer-reviewed literature, while other elements are lacking good evidence. We base our ideas on our experience in diverse countries and settings. We hope that bringing all these elements together into a unified approach will stimulate debate, highlight important research gaps and support policy-makers, healthcare providers and patient and community representatives working in this field. The first element, systems thinking, views health-care systems in a holistic manner and is often described as operating at micro- (clinical team), meso- (health facilities) and macro-level (health-care system). Systems thinking offers a useful framework for addressing the interdependency of these different levels that influence health-care delivery and health outcomes. (4) Interventions targeted to improve quality of care are unlikely to succeed or be sustained if designed without an adequate understanding of relevant contextual factors at these different levels. (5) Researchers and implementers are now recognizing the importance of these factors and their dynamic interaction in delivering safer, more effective care. (6) Failure to address these interdependencies may be particularly damaging in resource-poor settings, where constrained resources, lack of infrastructure and weak governance can exacerbate the difficulties of implementing an intervention. Examples range from unused expensive equipment due to lack of trained staff or electricity to operate it, to scarce health workers migrating to national and international organizations leading to understaffed primary, maternal and child care. Cultural and behavioural factors also affect these interdependencies and can contribute to problems during implementation. Interventions in resource-poor settings have to consider improvement across the different levels of the health system when trying to improve care at the clinical microsystems level. (7) Box 1 Elements to consider when improving health-care quality in resource-poor settings Systems thinking Health systems are dynamic complex adaptive systems, where all parts need to be considered. These parts are (I) the Inter-relationships between the patient, clinical and noncllnlcal workers In the health system; (II) the different levels of the health system ranging from the community to tertiary referral system; and (III) the required human and material resources and training, supervision and management structures. Participatory approach Participatory, grounded and bottom-up approaches Involving health-care professionals, patients and communities as well as researchers-in-resldence are Important to understand health systems. …