Each month the IHI Open School puts health care improvement experts on the hot seat and makes them answer your questions. 

This Month's Expert:

Patrick Lee, MD

Partners In Health, Kirehe, Rwanda — Volunteer Clinical Mentor
Newton-Wellesley Hospital, Newton, MA — Hospitalist Physician
Harvard Medical School — Clinical Instructor in Medicine

Dear Dr. Lee,

When it comes to doing improvement work in developing countries, how do you prioritize your goals given your limited resources?

          — Karen Born, PhD Candidate, Health Services Research, University of Toronto

Dear Karen,

Thanks for this outstanding question. It speaks to the heart of some of the most difficult and important decisions we face working in developing settings.

Given the time constraints (I have been given only one hour to reflect and compose this response), I will do my best to outline, in broad strokes, a few of the most important differences I have observed between improvement work in resource-rich and resource-poor settings. My perspective has been shaped by my work with Partners In Health in Rwanda, and I am grateful to all of the talented and dedicated Rwandan and American colleagues whose insights and experience I borrow from here.

Health care systems in developing settings suffer from varying degrees of inadequate funding in the face of often overwhelming public health challenges. Substantial and long-standing infrastructure and resource gaps may include lack of functioning hospitals and clinics, unreliable supplies of essential medicines and diagnostics, under-trained and/or under-paid staff, and so on. The list is long. Meanwhile, a lack of adequate primary care services means that a large backlog of untreated and advanced disease exists in the community. Improving care and long-term outcomes in resource-poor settings such as these means engaging in the very areas most debilitated by decades of harmful global trade, security, and health policies.

How, then, do we prioritize our efforts?

There is obviously much to be said here, and opinions will differ depending on local context and experience. In my view, three of the most important considerations are:

• Addressing substantial infrastructure and resource gaps
• Building broad consensus
• Responding to timely and appropriate monitoring and evaluation

In resource-poor settings, substantial resource inputs are necessary to both initiate and sustain improvement. In the area of Rwanda where Partners In Health works, for example, we had to build and renovate the district hospitals, outfit the health clinics with electricity and equipment, strengthen the supply chain for essential medicines and diagnostics, hire, train, and pay a fair wage to hundreds of Rwandan staff, supply food and bed sheets, and fill resource gaps all across the system. As Paul Farmer has observed, “In order to improve clinical services, you need to improve (and often build) the clinic itself.” Building capacity through substantial infrastructure and resource investments is an essential step toward breaking the poverty cycle and bringing about meaningful improvement.

Broad consensus is critically important to ensure the relevance, success, and sustainability of programs in developing settings. Consensus-building, in the briefest terms, means earning trust, giving local stakeholders a central role in planning and leadership, and carefully navigating the sociopolitical landscape to anticipate and avoid roadblocks to long-term political commitment. One analogy I like to use is to imagine tossing a bucket of water down a driveway. The water will run faster in certain areas and not at all in others. Consensus-building is like that. If our aim is to support lasting change (as it should be), we need to see deeply into the situation and position our interventions to take advantage of areas of greater flow and consensus. The good news is that change can sometimes occur more quickly in resource-poor than resource-rich settings because it does not have to work as hard against long-established systems and bureaucratic inertia.

To round out the top three considerations — mid-stream course-correction, in response to timely and appropriate monitoring and evaluation, can make the difference between solid and stellar program performance. This is where simple quality improvement tools and methodology are best applied. To take one example from our work in Rwanda, we found that by spotlighting two keystone patient care processes — taking vital signs and giving medications properly — we helped illuminate resource gaps and opportunities for system improvement all along the health care delivery chain. We observed downstream changes such as reorganized nurse staffing to promote ownership and accountability, anticipation of pharmacy stock-outs before they occurred, and a higher overall standard of care — all without direct prompting from our QI team. These changes were driven by an empowered medical staff, responding to daily performance feedback and motivated by early successes. This is only one example among many. Properly timed and targeted performance feedback can be a powerful agent for change, and should be thoughtfully integrated into improvement work.

Thanks again, Karen, for your insightful question and interest in improvement work in developing settings. I look forward to engaging with you and other health professions students around these issues through the month.

Got a question for Patrick Lee?  Email asktheexpert@ihi.org.

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