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Improving quality of care

Quality bottlenecks are in two domains: provider competency and provider effort and attitudes. How can these bottlenecks be overcome?
KRISHNA HORT: What are the bottlenecks to improve quality? And what strategies address them? Effective coverage requires that health care providers deliver services and provide care in accordance with agreed standards. There are two key bottlenecks to providers performing according to standards. And they’re in those two boxes in the middle of the slide, competency, the knowledge and skills to provide quality care, and the effort and attitude, the willingness and motivation of providers to provide quality care. This slide also demonstrates the key strategies and approaches that address provider competency and provider effort and strategies. Strategies can be grouped into those that primarily address competency, which are sometimes termed supply-side strategies, such as training, standards, and guidelines and supervision.
And then those that will primarily address effort and attitudes, demand-side strategies, such as vouchers, peer pressure, and consumer choice. And then in the middle, those that address both aspects, which we might term system strategies, such as payment mechanisms, laws and regulations, and market-based strategies. What is the evidence for what works? Direct supply-side strategies can improve knowledge and skills. But the evidence that these strategies alone lead to improvements in quality of care is quite weak. We conclude that training, supervision and guidelines may be helpful when combined with other strategies, but are unlikely to be effective on their own.
There is some evidence that some of the demand-side strategies, such as vouchers and conditional cash transfers, can lead to improvements in aspects of quality, although this depends on the extent of competition and choice for consumers, and the ability of providers to respond to consumer preferences. There is also evidence that some of the system strategies, such as payment mechanisms, are effective in improving access and utilisation of services with some impacts on quality, although quality has not usually been a focus of these strategies. However, they can be combined with other system reforms, such as universal health coverage, and may offer the most promise in the context of low and middle income countries.
Our brief review of the evidence suggests that a mix of strategies is needed, that combine the three different approaches of supply, demand, and system. One way to look at this is to combine individual focused intervention, such as regulating providers and improving competencies, with institutionally focused interventions, such as accreditation, strengthened accountability, and financial incentives based on payment mechanisms. Introduction of these strategies needs to be phased based on the capacity and willingness of the institution involved, which we might term the readiness, and must engage clinicians, particularly clinician leaders, to ensure success.
Useful guidance at a country level on how to plan and implement an appropriate mix of strategies can be found in the Implementation Guidance for Improving the Quality of Care for Maternal, Newborn and Child Health that was produced by the Network for Improving Quality of Care for Maternal, Neonatal, Child Health. This provides a series of seven steps, beginning with establishing leadership structures and building a coalition of support, then adapting and updating a framework of quality standards appropriate to the country, defining indicators and establishing a reporting system, assessing the structural system and human resource barriers, and the readiness for implementation, and commencing with pilots in demonstration districts using the Plan, Do, Study, Act cycle, measuring outcomes, and reviewing and revising those interventions.
Based on the learning from those demonstration districts, then institutionalise and roll out best practices and benchmark progress. As an indicator of country capacity and progress in the development and implementation of quality of care strategies, an assessment of country readiness was undertaken by WHO. Examples of the results of this assessment can be seen in this slide, which assesses the current situation in six countries, Bangladesh through to Uganda. It’s clear that some countries, such as Uganda, Ethiopia, and India, are well positioned to progress, while others have some key preparatory steps yet to be completed.
For guidance and introduction of implementation of quality of care initiatives at an individual facility level, the Every Mother Every Newborn Quality Improvement Guide for Health Facility Staff is a useful resource. This guide describes a phased approach for an individual facility, commencing again with engagement of the facility leadership, and establishing a QI team, then progressing to initial assessment, identifying effective interventions, developing plans and implementing of those interventions, followed by ongoing monitoring, and adaptation or scale-up. This approach uses the well-known Plan, Do, Study Act, or PDSA cycle, which is very popular in quality improvement circles. Finally, we will look briefly at two system level strategies, facility accreditation and payment mechanisms based on universal health coverage reforms.
Facility accreditation is quite an old approach, which originated in the United States, as a means by which hospitals could demonstrate better performance to potential consumers, and thus improve their market share. It is essentially a system strategy, strengthening accountability for the provision of quality care and combining improving capacity with providing motivation through recognition of achievement and sometimes financial incentives. It has been co-opted by many governments now as a compulsory government-administered program. However, it is important that the original ethos of learning, self-improvement, and peer support is not lost, as this encourages providers to continually improve the quality of care, rather than merely satisfying the required standards.
The pooling of funds and establishment of a single purchaser as part of a UHC program enables the purchaser to set conditions and requirements on payments. These may include initial requirements for facilities to be eligible to receive the payments, the linking of payment to a quality standard, such as providing higher reimbursement to accredited facilities, and selective inclusion of services and procedures in the benefit package eligible for reimbursement, and provision of additional investment funds to support quality improvement. All these measures provide financial incentives and disincentives that encourage providers to improve the quality of care they provide.

Kris summarised the quality bottlenecks into two domains: provider competency and provider effort and attitudes. Yet sometimes, health workers might have little power to change how they are managed by others. Despite their competency and effort, they might have poor managers who do not guarantee supplies, or managers who don’t support them when they are faced with long shifts or busy clinics.

While having competent and motivated health workers is central to quality care, there is strong evidence that it is insufficient, and strategies that focus on health worker competency may not result in quality improvement. Kris concludes by outlining other requirements: national leadership; routine facility level quality assessments and established quality improvement processes at every level.

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Health Systems Strengthening

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