Working group 3: Our 3-month update

Our last five months have been busy focusing on how to achieve the quality defined by Working Group 1, utilize the measures being developed by Working Group 2 and align with Working Group 4 to achieve quality health care for all. Our work is framed by the recognition that to achieve these goals we will need to expand our thinking beyond micro (local) level quality improvement approaches and instead consider systems-level levers at the macro (national) and meso (district) levels to drive change. We must consider governance, financing, pre-service education and other upstream strategies in our improvement pathways. We have even rebranded our working group as “Improving Quality” to expand the breadth of methods that we are capturing.

We have made tremendous progress in the last five months. Our analysis of health care provider performance in the first two years of clinical service is starting to show clear differences by country, variation that could be explained by the quality of pre-service education in that country. Categories of interventions are starting to emerge from a scoping review of the literature on ways to improve the experiential quality including relationship between providers and patients in LMICs. We are also finding that the body of published literature is still relatively sparse despite the importance of the subject. Our geographic models of health system redesign are suggesting that health systems can focus their maternity services on fewer, higher quality facilities without compromising access or quality of interpersonal care. We have encountered other gaps in the literature, both for emerging approaches as well as implementation-focused experiences from LMIC for more established quality improvement interventions. In some areas, such as optimal design of preservice training and its impact on quality of care, remains largely elusive.

What is truly amazing about this process is the participatory nature of the work. Our preliminary answers are the product of a collaboration between our commissioners, the secretariat, and experts from around the world – this is a true epistemic community. We can trace every improvement analysis to a question, idea or discussion that our working group had – Do learning collaboratives work? What approaches did countries who successfully met MDG 4/5 take to improve quality? How should we be thinking about equity, the patient voice, the private sector and the quality of evidence when improving health systems? How are countries institutionalizing quality and improvement? Evidence on these questions is often supplemented by insights based on personal experience or with support from our own incredibly rich professional networks.

As we refine our questions and learn more, we become increasingly interested in identifying the most critical set of interventions that LMICs should consider when improving health system quality. What interventions are best for what settings and how should they be adapted? How can we ensure that improvements are sustained and intentionally scaled up and out? Where should we be focusing our energy? To answer the broader question, we will continue to leverage this opportunity to bring research, policy and practice together. Not only must we look to where the evidence exists, but we also need to think carefully about how this knowledge can and will be applied, how the programs will be implemented and what practical issues must be considered in the various national and sub-national contexts where gaps in quality remain.