Quality improvement in the developing world

These reports from developing countries are good news both for the field of QI and for the many individuals working to improve health and health care systems in countries with very limited resources.

Abstract

Quality improvement in the developing worlddifficult.Erratic supplies of electricity and other fuels can A Quality Improvement (QI) team in a small clinic assessed threaten the 'cold chain' for vaccines.Add to this the comchildren's compliance with a standard treatment plan for a bined burdens of diseases such as cholera, malaria, and AIDS, common infectious disease.Compliance was poor.Studying the effects of chronic malnutrition, and the new 'double why, the staff discovered that the bad taste of the medicine burden' of chronic illnesses.Not surprisingly, studies of was a principal problem.Working with mothers, the QI team the quality of services in such settings are almost always identified popular foods that could be used to conceal the pessimistic [3].taste, and they placed in the waiting area a poster showing Developing countries face structural problems as well.how to use the foods to do it.In the next test cycle, While every country is different, 'top down' management compliance with the treatment protocol had risen from 48% systems, many of them legacies of colonialism, are common.to 70%.Developing countries, like their wealthier counterparts, can The story is familiar-a successful quality improvement rarely monitor the quality of services delivered to discover project-but the setting is not.The project team was not in underlying causes of failure, or to determine when ima wealthy American health maintenance organization or a provements (or deteriorations) have occurred.primary care practice in Sweden.In was in a remote AfricanIn addition, some of the most sophisticated efforts by village, the disease was malaria, and the drug was chloroquine developed countries to offer help have brought their own [1].accompanying problems.Many donors, including very large In conjunction with this issue, the International Journal of comprehensive agencies such as the World Health Or-Quality in Health Care will publish a supplement entitled ganization (WHO), have offered assistance for one disease 'Quality Assurance in Low-and Middle-Income Countries'.at a time.Special projects to eliminate cholera or treat The papers in this supplement are based on the work of the malaria can have great benefit, but the patients who present Quality Assurance Project of The United States Agency for themselves for care do not come sorted into diagnostic International Development (USAID), now in its third 5-year categories.At the primary care level, and for care of AIDS, funding cycle.These reports from developing countries are tuberculosis, and chronic illnesses, integration is essential.good news both for the field of QI and for the manyThe Integrated Management of Childhood Illnesses (IMCI) individuals working to improve health and health care systems illustrates a change in approach that will also stimulate in countries with very limited resources.interest in QI.This major initiative, which is currently being This project has a technical support center in the United implemented in over 100 countries, is sponsored by WHO States, which provides assistance to developing countries that and the United Nations Children's Emergency Fund request it and compete successfully for funds from the local (UNICEF), and is now also supported by many other donor USAID mission.Readers who would like a preview of agencies.Its aims are 'to reduce death, illness and disability, the supplement can sample the impressive collection of and to promote improved growth and development among monographs, case studies, and research reports available on children under 5 years of age ' [4].IMCI emphasizes the the project website [2].The supplement includes reports of work in some of the comprehensive care of children.The project focuses on systemic capacity for predictable routine care.The critical poorest countries in the world.The basic approach is simple and familiar: set improvement goals, study the work process, elements include clinic access, availability of essential supplies, and health worker performance including communication design and test promising changes, measure progress, involve everyone, and continuously build skills in system-mindedness, with patients.IMCI's first implementation step is an inventory of the teamwork, and measurement.Throughout, listening carefully to clients and respecting their needs is a clear abiding principle.level of quality of services currently delivered.A few of these studies have been published [5,6]; many more exist as The results speak for themselves: QI works in unfamiliar places.consulting reports prepared for the Ministry of Health that requests them.An important part of the process is continued Working conditions in developing countries can be overwhelming, and include lack of sufficient staff, absence of measurement of the level of achievement of objectives such as immunization rates, compliance with treatment protocols, continuing education, poor physical facilities, and long distances between health centers.In rural settings where much and numbers of children weighed during their primary care visits.By measuring and reporting how facilities function, of the population lives, bad roads and incomplete coverage by telephone systems make transportation and communication and by using that information to identify both successful and