At the Wilson Center conference on Maternal and Child Survival (from left to right): Lily Kak (USAID), Dr. Jesca Sabiiti (Uganda Ministry of Health), Dr. Blerta Maliqi (WHO), Dr. Margaret Kruk (Harvard University), and Dr. Sodzi Sodzi-Tettey (IHI).
Recently, I spent some time in a country with leaders who shared their frustrations with me about a multi-year improvement project in its final months. “[The international NGO] did not work with us,” they complained, “so we don’t know what they did!” These sentiments at project close-out signal that very few best practices will be sustained, if any. This means costly, lost opportunities for lasting change. I fear that any prospective partner who refuses to sufficiently acknowledge and respect health systems leaders in this country will increasingly face resistance, hostility, and — in the most extreme cases — be driven out.
It doesn’t have to be this way.
Working in multiple countries as head of IHI’s Africa region, I am inspired by ministries and governments who fully embrace their roles in reversing poor quality care, inequities, and disrespect. They lead quality efforts that are country-owned, co-designed, and jointly implemented. This approach actively prevents temporary success attained by outside organizations that bypass existing quality management structures and result in unhelpful publications that only tell half the story about a project.
Put Quality at the Center of Universal Health Coverage
In 2018, we have seen three seminal quality reports on health and health care with recommendations for global action. Publications from the World Health Organization (WHO), World Bank, and Organization for Economic Cooperation and Development; the US National Academy of Sciences, Engineering, and Medicine; and the Lancet Global Health Commission on High-Quality Systems inspire us to place quality care at the heart of the global aspiration for universal health coverage. Put more succinctly, achieving better health care access for more patients without addressing poor quality care may well amount to empty and unwelcome rhetoric.
The timing of these reports could not have been better. What I witnessed at the recent interactive round table discussion organized by USAID’s flagship Maternal and Child Survival Project at the Wilson Center in Washington, DC, confirmed this, especially after hearing Jesca Nsungwa Sabiiti, MBChB, Mmed pead, PhD, Acting Commissioner in charge of Community Health for the Ministry of Health in Uganda.
Articulated in the Swahili phrase “Hakuna Muchezo” — which translates as “no time for games” — Uganda is making clear that improving population health outcomes is serious business. They aim to transform maternal, newborn, and child health outcomes by focusing on “quality service delivery, accountability for results and getting value for money.” By so doing, Uganda is simultaneously rallying the world to action at an auspicious moment in the quality of care field.
Dr. Sabiiti outlined various national interventions to sustain declining maternal and child health outcomes, and address stagnating newborn deaths. According to Dr. Sabiiti, Uganda aims to save “an additional 6,350 maternal, 30,600 newborns and 57,600 children’s lives (2-59 months) over the next five years.” Key interventions include galvanized actions in communities and high-burden health facilities; strengthened structures for supervision, monitoring and evaluation; set up of technical working groups and quality improvement teams at regional and facility levels; and a strong focus on decentralization for local ownership and accountability.
According to Dr. Sabiiti, “We have adapted the WHO quality [maternal and newborn child health] standards to ensure a fully functional service delivery at all levels. We have also combined internal and external facility assessments leading to rating of facilities, developed training manuals for frontline staff and facilitators and finally, we are using a resource tracking tool to better coordinate multiple funding mechanisms.”
Placing quality at the heart of the UHC conversation is serious business. There is no time for games. We need committed, coordinated action. There are five critical strategies that ministries, development partners, and funders all need to embrace as we position ourselves in mutually supportive technical collaboration:
Embrace multiple strategies to transform care. IHI will soon publish lessons from case studies from five countries implementing National Health Care Quality Strategies. Ethiopia, Nigeria, Ghana, Scotland, and Mexico all demonstrate the value in having a complementary focus on quality planning, quality assurance, and continuous quality improvement. Other countries are also directly linking reimbursement under national health insurance schemes to the attainment of clear quality goals. No one method is superior, with the development of a supportive policy environment, clinical protocols, assessments and accreditation, and team-based quality improvement approaches all serving to close quality gaps. Specifically, ministries and governments should aim for National Quality Strategies that embrace this broad quality agenda supported by detailed practical implementation plans that connect lofty national aspirations to site-level activities at the point of care.
Support effective coordination. Weak coordination of multiple quality interventions slows progress to population-level impact. Many countries are still grappling with functional governance systems that do a great job of diagnosing system gaps, prioritizing for intervention at various levels, commissioning quality improvement teams with ambitious targets, harvesting best practices for scale and promoting multiple feedback loops in a dynamic quality management system. Partners need to provide highly aligned technical assistance that enables ministries to roll out quality governance structures that diagnose system gaps using a set of quality metrics, and commission quality management teams for action.
Identify and engage sustainable funding sources. We need to squarely face the reality that implementing various strategies to improve care costs money. IHI recently estimated that the implementation of Ghana’s five-year quality strategy would be $40 million. This is a significant financial commitment. As we embrace the era of “country-led interventions,” tout “transition to local organizations,” and “life beyond aid,” it is critical for governments to adequately budget for planned interventions to improve quality. This may be complemented by more effective coordination of resources from donors and partners working on separate but aligned initiatives. Funders planning to inject resources into specific quality initiatives simultaneously need to have robust conversations with governments on co-funding options and their possible tradeoffs. We need to make practical arrangements to achieve what I view as the “triple aim” of co-design, co-funding, and co-implementation.
Build capacity and capability. It will take an integrated approach to build QI capacity and capability and clinical subject matter expertise and skills. Health system competencies need to be targeted. Key health system competencies that enable improvement actions are effective leadership at all levels, resource mobilization and management, reliable use of data, and coaching and mentoring. There is, therefore, the need to build capacity by using appropriately tailored curricula for high-level leaders, middle-level managers, frontline providers, and data officers. Beyond didactic one-off trainings, partners need to design technical content that is applicable to actual problems faced by health workers.
Start with scale in mind. Countries are quickly moving beyond successful but unscalable pilots. Two components for successful scale up are key: content (the what) and process (the how). It is imperative that we complement the evidence of what was done to improve health outcomes by isolating how critical changes in the workings of the health system made change possible. Leaders of health systems can no longer proceed on the assumption that we can simply impose new content onto old ways of working and expect significant new effects. New ideas will benefit from redesigned work processes to support their effective implementation. Through co-design, governments and partners must commit to rapidly scale best practices and fundamentally alter outdated work processes that add no value to the process of care.
Hopefully, we are nearer our shared vision to move beyond merely universal access to guarantee quality care for all. “Hakuna Muchezo!” It is time for change!
Sodzi Sodzi-Tettey, MD, MPH, is Executive Director and Head of the Africa Region of the Institute for Healthcare Improvement.
You may also be interested in:
WHO-OECD-World Bank joint publication – Delivering quality health services – A global imperative for universal health coverage
The US National Academy of Sciences, Engineering, and Medicine – Crossing the Global Quality Chasm: Improving Health Care Worldwide
Lancet Global Health Commission on High-Quality Systems in the SDG Era – High-quality health systems in the Sustainable Development Goals era: time for a revolution