Quality Improvement: A Health System Strengthening Priority

Health systems strengthening: a global health care challenge

The DRC is hardly alone. Health systems in many developing countries grapple with numerous complex challenges, from a broad array of diseases, escalating care costs, and decentralized management structures to inequitable health, regulatory obstacles, and a shortage of healthcare professionals. These challenges transcend the care an individual provider or facility offers but affect that care. They underscore the need for efficient organizational structures and processes to govern, manage, and finance health systems effectively.

Quality improvement (QI) principles can serve as a cornerstone in addressing these larger issues. Combined with a culture that prizes data-driven decision-making, QI offers a robust framework to eradicate inefficiencies in organizational systems and processes. That, in turn, improves system performance and, as the DRC shows, can contribute to better health outcomes for patients.

Quality in a health system encompasses several dimensions, including safety, effectiveness, efficiency, timeliness, patient-centricity, integration, and equity. They should be part of every facet of a health system, from roles and rules to relationships. Poor quality measures and standards threaten patients by, for example, creating unnecessary administrative burdens that can compromise access to treatment and thus patient well-being. Administrative obstacles range from discrimination to the need to navigate multiple facilities for required services. 

Understanding Quality Improvement Principles

When health system actors follow quality principles, their understanding of the system enables them to take ownership for solving problems. The core principles of quality improvement and the iterative, data-driven methodology to implement them apply across sectors. The principles include:

• a commitment to understanding the system
• identifying bottlenecks
• testing changes to processes to improve system functions
• measuring changes and using data to track progress
• engaging a broad group of stakeholders
• fostering a culture of continuous learning
• sharing knowledge with a focus on client needs, values, and preferences.

Traditionally, QI initiatives in health focus on improving service delivery processes at the point of care: a clinic, hospital, or doctor’s office. The aim is to curtail human errors, enhance service quality, and improve patient-centered outcomes and satisfaction. This approach ensures that a health facility's performance aligns with a nation's broader health objectives. But if the facility lacks needed equipment because of a lack of funds or supply chain issues, the facility can’t provide quality care.

What’s more, the focus on facilities fails to recognize that versatile QI methods apply to critical organizational functions within a health system. For instance, within human resources, performance appraisal and feedback systems provide employees with a structured platform for growth and development. Regular assessments and constructive feedback foster a culture of continuous learning, enabling employees to voice concerns and identify potential avenues for improvement. These methods also find applicability in inventory and resource management systems, budgeting and financial analysis, patient flow information technology systems, regulatory audits, and policy reviews.

Challenges and Opportunities in Implementing Quality Improvement

While the potential benefits of quality improvement methods are profound, implementing them within health system management structures faces challenges. Overcoming entrenched top-down management styles in favor of collaborative approaches requires cultural shifts—a significant hurdle. Additionally, fostering a culture of continuous improvement and curiosity requires a departure from the traditional "blame culture" that often pervades health systems in developing countries. Additional challenges include issues related to data quality and accessibility, interoperable health information systems, resource constraints (including time, human, and financial), and the lack of effective communication and collaboration among various health system actors.

Abt Global: Exemplifying Success through Quality Improvement

Integrating quality improvement into health systems management processes and interventions shows the transformative potential of these principles. Abt’s projects exemplify the possibilities when QI principles are infused throughout health systems. Rooted in data-driven decision-making and a culture of improvement, QI offers a robust framework to address the complexities of modern health systems. Below we provide a few examples that serve as beacons of what is possible.

IHP addresses maternal mortality in the DRC.

Even after an 18 percent decline between 2000 and 2020, the DRC still ranked 11th in the world in maternal mortality rates. Recognizing the urgency of addressing this longstanding problem, country leaders identified the enhancement of health systems quality as a pivotal solution. This strategic decision aimed to tackle the root causes of maternal mortality, underscoring the vital role that improved health systems play in safeguarding the well-being of women during childbirth.

To enhance health systems quality, the DRC IHP project embarked on a transformative journey by strategically integrating quality improvement approaches into health system operations. The project initially focused on key activities such as clinical mentoring and integrated supervision. However, recognizing that these alone could not address quality challenges, the project collaborated with the Ministry of Health and partners to consolidate various quality improvement approaches into an integrated framework. This holistic framework went beyond clinical care, encompassing broader health system elements such as medications, data, equipment, infrastructure, and more.

Three pivotal tools formed the cornerstone of IHP’s efforts: Participatory Institutional Capacity and Learning Assessment (PICAL) to assess organizational, administrative, and institutional capacities; Community Performance Bulletin (BCP) to foster community engagement and accountability and track progress around health areas to inform decision making; and Integrated Quality Approach (DQI) to track services quality and improvement to inform improvement plans, policy formulation, and national health strategies.

Implemented Scorecard: Strengthening the Quality Improvement (QI) process in primary health care facilities

In Nigeria, the Basic Health Care Provision Fund (BHCPF) is a health financing initiative to enhance the quality of care for the poor in selected primary health care facilities. The BHCPF uses a QI process that incorporates quarterly quality assessments and business plan development. The BHCPH facility assessment scorecard is a tool used to monitor the progress of facility quality improvement and to inform the development of a quarterly business plan, which serves as the guide for quality improvement-related expenditures.

With support from the LHSS project, the BHCPF's data collection for quality assessments has transitioned to a mobile phone application, streamlining processes to increase data timeliness and accuracy. This collaborative effort, spanning Plateau, Zamfara, and Nasarawa States, aligns with the LHSS project's broader objective of strengthening health systems to achieve universal health coverage (UHC). The project focuses on reducing financial barriers, increasing health coverage for low-income households, and improving the quality of essential health services.

The BHCPF's QI process linking quality of care to financials through a structured approach encompassing quality assessments, business plan development, and financial reporting is innovative and promising. Challenges with the scorecard, including variations in assessors' measurement interpretations and the need for benchmarking for clinical service utilization, underscore the importance of continuous process refinement.

Nonetheless, strengthened use of this process at the facility, local government, and state level can significantly improve quality and value for money for direct facility financing– a critical outcome given the current BHCPF reform being undertaken by the new administration that will lead to increased funding to facilities. For example, in Nasarawa State, quality assessment covered 147 BHCPF facilities with a 100% completion rate and improvements in financial systems management metrics from 73 to 87% over six months. 

Applying QI methods to strengthen health systems operations and performance represents a relatively new frontier and has not been extensively tested. If the benefits approach those at the services level, they could be profound. As more governments adopt QI methods, it will be critical to evaluate their performance to assess whether they live up to their promise. Any assessment is likely to detect gaps. At that point, it may be time to use QI methods on the QI approach itself. 

We wish to acknowledge the important contributions of our colleagues on the DRC IHP, Nigeria LHSS, and Mozambique IFPI teams.