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

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

Read a first-person account of the work Dr. Lee and his teammates did in Kirehe, Rwanda.

Dear Dr. Lee,

In a resource-poor setting, a lot of the infrastructure we depend on for quality improvement (for instance, information technology) is not available. What are some specific examples of how you might handle this problem?

      — Heather Bennett, MS4, University of California, San Francisco, School of Medicine

Dear Heather,

How do we handle infrastructure limitations? First, we keep things simple and stick to the basics. I’d like to share the comments of my colleague and teammate, Meera Kotagal (Harvard Medical School, MS4), on this topic. She writes:

“Many of the tools at the core of quality improvement methodology are very low-tech. You don't need computers or information technology to plan PDSAs, brainstorm, sketch out process maps or FMEAs (Failure Modes and Effects Analyses), or make run charts. You just need a pen, paper, and a willingness to think outside the box. Being faced with limited resources also forces you to be creative, to get from point A to point B in three steps rather than fifteen because you can’t afford the fifteen steps.”

In other words, you don’t need high-tech tools to begin improvement work. (Scroll down to see the photos of our team’s pen-and-paper wall charts in Kirehe, Rwanda.)

We can often make substantial gains in clinical care by making better use of the tools we do have. In resource-rich and resource-poor countries alike, we can save many lives by closing the gap between what we know and what we do. In developed countries, for example, the reliable delivery of aspirin for patients with heart attacks is a simple intervention that has saved many thousands of lives.[i] In Kirehe, we focused on a range of clinical “low-hanging fruit” such as appropriate fluid resuscitation in sepsis or partogram use for all women in active labor.[ii,iii] These are just two high-impact examples among many.

But it isn’t enough to make better use of existing resources. We must also build the human and infrastructure capacity to deliver life-saving technologies to the poor communities who need them. To take one example, anti-tuberculosis drugs (often available in resource-poor settings) are only the starting point for an effective anti-TB program. Other important components include chest x-ray and sputum microscopy to diagnose the disease, community health workers to directly observe therapy and quickly identify potentially resistant cases, well-trained medical personnel, food to treat the associated malnutrition, adequate housing to prevent overcrowding, and so on.[iv] Building this kind of basic capacity, I would argue, is the foundation of improvement work in resource-poor settings. Simple tools such as PDSA cycles and process maps are most useful when paired with a robust commitment to infrastructure development.

One final point. Let’s not forget the role of advocacy in overcoming resource limitations all over the world. Too often we ask how to improve care in resource-poor settings without also asking why, in a world of unprecedented prosperity, we allow this kind of poverty to exist at all. Being born poor should not be the strongest predictor of an early death, but it is.[v,vi] We have to change the idea that poverty and inadequate care are inevitable in certain parts of the world.

Let’s update Virchow’s assertion, “Physicians are the natural advocates of the poor,” to include all professionals interested in improving care in developing settings. Let’s all of us — clinicians, program managers, policy- and lawmakers, conscientious global citizens — remember to look up from the tasks at hand and advocate for a more just world.

Thanks so much, Heather, for your excellent question and your interest in infrastructure development. We are part of a groundswell of young health professionals committed to improving access and quality of care around the world. I believe this is cause for cautious optimism, and I look forward to engaging these problems with you and others in the years to come.