Quality of care in low- and middle-income settings: what next?

For decades or longer, efforts to improve health in resource-limited settings focused on fundamental public health interventions , including sanitation, immunization and access to basic primary care. These interventions are paramount to reducing preventable mortality and increasing life expectancy. Nevertheless, as low-and middle-income countries (LMICs) experience economic development, calls for improved quality of care within both primary and secondary care settings have emerged [1– 3]. The challenge is manifold. How to continue to expand access to preventive and primary care, while satisfying growing needs in clinical and secondary care? How to elevate quality without sacrificing access to services, particularly in resource-limited settings? These issues, we hope, will be harbingers of future health-care innovations that effectively address questions of cost, access and quality in LMICs. The science of health-care quality improvement, first brought to the USA through the National Demonstration of Quality Improvement in Health Care [4], is now widely endorsed by practitioners, researchers and policymakers in high-income settings. Decades of theoretical and empirical research has identified key elements of successful quality improvement efforts [5 –9]. These include: (i) common vision and shared goals across the hierarchy of those planning and implementing improvement efforts, (ii) reliable, credible and timely data and (iii) an organizational culture of accountability without excessive individual blame. These elements are not easy to achieve and sustain in any environment, but special circumstances of LMICs may create greater challenges and highlight the need to develop a literature on essential elements of successful quality improvement efforts that are specific to these settings. A first special circumstance is the donor– recipient relationship that underpins the health systems' strengthening efforts that frame much of the quality improvement work in LMICs currently. Many quality improvement projects are initiated and funded by governmental and non-governmental agencies outside the organization and often outside the country altogether [10]. Although the vision and goals may become aligned as ministries of health and organizational leadership teams enroll in such efforts, typically enrollment in these projects includes higher salaries, financial inducements and increased prestige that may result in increased flow of project-based resources in the future. This imbalance of power may have deleterious effects on the motivation of staff and policymakers, who may not internalize the common vision and shared goal of improvement. Rather, they may implement prescribed processes so that they can access project-based financial and non-financial resources. Sustaining motivation for continuous improvement from within the organization …