• quality of care
• quality methods
• developing countries

Quality methods used in health care have been developed in Western health systems. Here there is a growing awareness of the waste and risks caused by problems rooted in systems of care which are not well organised. Governments and others are making resources available to address these problems, and this is being seen as a necessary investment to save money and unnecessary patient suffering. In contrast, in lower income countries the development and quality of health services is severely limited by lack of resources and knowledge about quality methods.

Despite these differences, however, lower income countries increasingly recognise the value of quality methods and the need to raise the quality of their services. Many are making more use of quality methods, but the traffic is not one way—the West can also learn from their experiences of improving quality and safety. It is worth remembering that quality methods were first developed and put into widespread use in Japan after the Second World War—a country with few resources—and then re-imported into the West. This editorial considers some of the challenges in applying and adapting quality methods in these countries, as well as the potential for testing and developing more cost effective methods, some of which may be valuable for Western health care.

There are severe limitations to health care in most developing countries. One perhaps extreme example from a current programme in a low income Arabic country is presented here. The average spend on public health care per head of population is $6 a year, and it is falling every year. Although there are many health facilities, the services are unevenly distributed and there is a lack of many essential drugs (despite various programmes to solve this problem) and inappropriate prescription. Health personnel are undertrained, unsupervised, and morale and incomes are low (about $10 a month for doctors). Patients make little use of the public health system: co-payments have been introduced but quality has not improved. An unregulated private sector is fast expanding with a large pharmaceuticals market. Poor diagnosis and inappropriate treatments waste many resources and cause unnecessary suffering and mortality. One district hospital is typical: an occupancy rate of 12%, 140 staff (45 doctors, seven of whom are from overseas and cannot speak the language), and diagnostics and treatments which are often ineffective or unsafe. Add to this the situation for women where the average fertility rate is 6.8 children per woman, there are few women doctors, and few mother and child services.

“Many [developing countries] are making more use of quality methods, but the traffic is not one way …”

Surely the issue here is how to improve the performance of the health system and how to establish a basic infrastructure which includes training and management capacity building? In a situation like this, some take the view that quality methods and concepts are irrelevant. There is certainly a case for arguing that some quality approaches are inappropriate—for example, large amounts spent on accreditation systems to improve the quality of tertiary hospital services could be put to better use. Accreditation is certainly more easy to understand than many other quality methods and it is often supported by donors, but it is often unsustainable, ineffective and inappropriate in many of these countries. In my experience, quality methods have an important part to play in improving the performance of the health system if the right ones are chosen for the situation and adapted in a culturally appropriate way. If the money used for the accreditation system was invested in quality methods to improve immunisation programmes or drug supply logistics, many more lives would be saved and the changes would be sustainable.

Even though quality methods might seem a luxury, the country in the example—in common with an increasing number of developing countries—has introduced a national health quality strategy. Is this political “window dressing” or a response to aid donor’s concerns? To some extent it is both, but also more. Highlighting quality as a problem and saying that something needs to be done is a popular move but of little use unless a low cost way can be found to get results. At the same time there is a genuine determination among some managers and practitioners to do something about the quality of services, and also a belief that quality methods might have something to offer, if only because they come from a part of the world that has brought mobile telephones and cars which work.

As one of a number of quality experts working in developing countries, I have been challenged to propose appropriate strategies. In Arabic culture, with different management traditions, I have been forced to recognise how much quality methods presuppose an attitude, way of working, and certain management processes. The relation between the Ministry of Health and local districts, ruled by tribal leaders, is more one of negotiation than direction. Introducing quality systems also means introducing management processes which challenge the existing power structures and culture and are quickly rejected. In many such countries, but not all, multidisciplinary improvement teams do not work because traditional authority structures or team approaches have to be adapted for the culture—some might say this is also true of the West.

To make progress it is necessary to find able managers and practitioners, show them the different approaches, and work with them to adapt and test what they think might work. As in the West, there are many who argue that an expansion of the existing system is all that is necessary: more doctors and nurses doing what they do now. Others argue that reallocation of resources is the way: more personnel in primary care and fewer in secondary and tertiary care. Others propose that stronger management and decentralisation is necessary to improve quality. And there are a few who propose using quality methods specifically to address problems in how care is provided and in support services. As in the West, there is debate about how many resources should be diverted into quality activities and a growing recognition that this will be a permanent extra resource demand. The choices are starker and the need for the investment to “pay off” is greater.

Although at first not knowing where to start, Ministry and local managers decided on an interesting mix of approaches. One is to define a “standard package of services” for health centres and units across the country—this definition does not itself bring such services to all areas, but it is a step in that direction. They rejected certification, stronger licensing, and accreditation at this stage, and decided to trial a quality management system in selected districts. Past experience has been that large numbers of standards have been developed but not followed. The trials have chosen a few health conditions where following standard procedures would make care more effective—for example, the diagnosis and treatment of acute respiratory tract infection. The emphasis is on training, supportive supervision, and action using problem solving methods to ensure these few standards are followed, then to add more standards.

One reason for choosing this approach is that it is a small achievable step which may help with the problem of motivation and incentives for health workers. Workers are finding that more effective care means more patients and higher incomes. Supervisors are more welcome and are being questioned about correct procedures for other treatments. Other approaches are being used to upgrade clinical skills and to address problems of morale and discipline. There are lessons for the West in the careful way in which policy makers with few resources analysed which issues were amenable to action and which issues were too large to take on in the early stages of the programme. There are also lessons from the way in which the donor who contributed to this programme helped address the sustainability issue: how successful projects could be transferred into routine operations with the resources to support continued quality activities.

This approach is not typical of all developing countries, but what is typical is the way in which colleagues in these countries are adapting and experimenting with quality methods. They are increasingly sceptical of “quality packages” from the West which are said to cure the ills of their health systems. Certainly many quality methods transferred from the West are unaffordable or unsustainable, and many do not translate. This raises the question of whether there is an equivalent to Maslow’s “hierarchy of needs” for quality methods—where certain steps need to be taken first before using the methods of more sophisticated continuous quality improvement or other approaches? Or are the new approaches being developed suited to the different cultures and limited resources, but could also be effective in the West?

Quality methods are severely tested in developing countries and, as in the West, many do not work in certain cultural and economic circumstances. However, the need to improve quality in these countries is as pressing, if not more so, than in the West. Some able colleagues are adapting and pioneering new methods and new approaches to using these methods, from which the West can learn. It is to be hoped that more reports of these programmes and experiments could be published in international quality journals. Dialogue and debate about effective methods in different circumstances would be of benefit, especially to patients in these countries and, in the long term, to patients in the West.