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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

IMPROVING QUALITY OF
CARE IN LOW- AND MIDDLE-
INCOME COUNTRIES

WORKSHOP SUMMARY

Gillian J. Buckley and Rachel E. Pittluck, Rapporteurs

Board on Global Health

Institute of Medicine

images

THE NATIONAL ACADEMIES PRESS

Washington, DC

www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

THE NATIONAL ACADEMIES PRESS     500 Fifth Street, NW     Washington, DC 20001

This activity was supported by Contract/Grant No. APC-GM-0002 between the National Academy of Sciences and JSI Research and Training Institute/U.S. Agency for International Development. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-37342-5
International Standard Book Number-10: 0-309-37342-5
DOI: 10.17226/21736

Additional copies of this workshop summary are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2015 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2015. Improving quality of care in low- and middle-income countries: Workshop summary. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Ralph J. Cicerone is president.

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The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

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Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

PLANNING COMMITTEE FOR THE WORKSHOP
ON IMPROVING QUALITY OF CARE IN LOW-
AND MIDDLE-INCOME COUNTRIES1

SHEILA LEATHERMAN (Chair), Research Professor of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill

RIFAT ATUN, Professor of Global Health Systems; Head, Global Health Systems Cluster, Harvard T.H. Chan School of Public Health

KEDAR MATE, Senior Vice President for Innovation, Institute for Healthcare Improvement; Assistant Professor of Medicine, Weill Cornell Medical College

IOM Staff

GILLIAN J. BUCKLEY, Program Officer

RACHEL E. PITTLUCK, Research Associate

DAVID T. GARRISON, Senior Program Assistant (from June 2015)

FAYE HILLMAN, Financial Associate

PATRICK W. KELLEY, Director, Board on Global Health

_________________

1 Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

Reviewers

This workshop summary has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary:

A. Mushtaque R. Chowdhury, BRAC, Bangladesh; Columbia University Mailman School of Public Health

Corine Karema, Ministry of Health, Rwanda

Nachiket Mor, CARE India; Reserve Bank of India; CRISIL

Edward B. Perrin, University of Washington

Alexander Rowe, Centers for Disease Control and Prevention

Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop summary was overseen by Robert S. Lawrence, Professor of Environmental Health Sciences, Health Policy, and International Health, and Director, Center for a Livable Future, Johns Hopkins Bloomberg School of Public Health. He was responsible for making certain that an independent examination

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

of this workshop summary was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the rapporteurs and the institution.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

Acknowledgments

This report is the product of the cooperation and contributions of numerous people. The planning committee and project staff are especially grateful to the presenters and moderators who participated in this workshop, lending their time and expertise to make the event a success. These individuals are listed in the workshop agenda in Appendix A. We would also like to thank the many participants who attended the workshop, both in person and via the live webcast.

Many staff of the Institute of Medicine and the National Academies of Sciences, Engineering, and Medicine have supported this activity from its inception to the workshop itself and through the publication of this workshop summary report. In particular, we wish to acknowledge the efforts of Daniel Bearss, Marton Cavani, Chelsea Frakes, Greta Gorman, Faye Hillman, Sarah Kelley, Ellen Kimmel, Rebecca Morgan, and Jose Portillo.

The planning committee and staff thank the U.S. Agency for International Development (USAID) for generously funding this activity.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

This page intentionally left blank.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

3-7 The modified plan-do-study-act cycle that forms the basis of SBM-R

3-8 An SBM-R standard for antenatal care

3-9 Results from a comparative study showing the trends in maternal and newborn health care practices after SBM-R was implemented in 102 facilities in Mozambique, 2009–2013

3-10 Results from a comparative study showing the trends in maternal health service delivery practices and health outcomes after SBM-R was implemented in 102 facilities in Mozambique, 2009–2013

3-11 Active management of the third stage of labor (AMTSL) and post-partum hemorrhage rates, in participating Nigerien hospitals, January 2006 to December 2008

3-12 The capability, opportunity, motivation model of behavior change

4-1 Breakdown of the strategy studies by region

4-2 Weighted median adjusted median effect sizes (MES) and interquartile range (IQR) for selected strategies

4-3 The timeline for developing the iSanté electronic medical records (EMRs) system

4-4 The OECD health system performance assessment framework

4-5 The possible outcomes accounted for in a hypothetical cost-effectiveness analysis of a quality improvement program in a Liberian district health center

4-6 A quick literature review of cost-effectiveness studies indexed to PubMed found only 10 papers included cost-effectiveness analyses

4-7 General structure of economic evaluations

5-1 The know-do gap in correct treatment by case among different types of providers in India

5-2 A review of clinic records 6 months after the standardized patient (SP) visits raised concerns about missing and erroneous information

5-3 The audit cycle

6-1 Tradeoffs in improving quality

6-2 Combining three key questions with a plan-do-study-act cycle is a model for improvement

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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TABLES

3-1 Differences Between Quality Assurance and Quality Improvement Methods

3-2 The Accreditation Process, Including the Typical Timeline in Developed Countries

3-3 Results from a Controlled Evaluation of Noncommunicable Disease Compliance in the Republic of Georgia, Showing the Percent Difference Attributable to the Collaborative Intervention

3-4 Summary of the Nine Types of Comparisons Examined in a Cochrane Review on the Effects of Supervision on Quality of Care

4-1 Definitions of the Six Strategies Using Component Variables from the Health Care Provider Performance Review (HCPPR) Database

4-2 Number of Studies in the Health Care Provider Performance Review Database Comparing an Active-Strategy Group with a No-Intervention or Historical Control Group

4-3 Breakdown of the Risk of Bias in the Strategy Studies

4-4 Breakdown of the Strategy Comparisons by Study Design

4-5 Breakdown of the Strategy Studies by Setting

4-6 Breakdown of the Strategy Studies by Health Care Provider Type

4-7 Breakdown of the Strategy Studies by Health Condition

4-8 Breakdown of the Strategy Studies by Method of Data Collection

4-9 Broadening the Definition of Improvement Collaborative with Low-Intensity Training to Adjust for the Probable Confounding of Limited Variability Sharply Reduces Estimates of Effectiveness

4-10 Types of OECD Health Systems Indicators

4-11 Number and Percentage of 26 Asia-Pacific Countries Reporting Selected Components of a Quality Improvement System

5-1 Variability in Key Health Indicators by World Bank Income Group in 2013

5-2 Proportion of Providers Adhering to Various Treatment Guidelines in the Public Sector (PHC), Private Sector Non-Intervention (control), and Private Sector Intervention (treatment) Groups

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×

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Page xvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Acronyms and Abbreviations

AIDS acquired immune deficiency syndrome
AMTSL active management of the third stage of labor
ART antiretroviral therapy
ASSIST Applying Science to Strengthen and Improve Systems
CDC Centers for Disease Control and Prevention
COPE® client-oriented, provider-efficient services
DALY disability-adjusted life year
DHS Demographic and Health Survey
Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria
HIV human immunodeficiency virus
IOM Institute of Medicine
IQR interquartile range
MES median effect size(s)
MESI Monitoring, Evaluation and Surveillance Interface
OECD Organisation for Economic Co-operation and Development
Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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PEPFAR The President’s Emergency Plan for AIDS Relief
SBM-R Standards-Based Management and Recognition
URC University Research Co., LLC
USAID U.S. Agency for International Development
WHO World Health Organization
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
×
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2015. Improving Quality of Care in Low- and Middle-Income Countries: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21736.
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Quality of care is a priority for U.S. Agency for International Development (USAID). The agency's missions abroad and their host country partners work in quality improvement, but a lack of evidence about the best ways to facilitate such improvements has constrained their informed selection of interventions. Six different methods - accreditation, COPE, improvement collaborative, standards-based management and recognitions (SBM-R), supervision, and clinical in-service training - currently make up the majority of this investment for USAID missions. As their already substantial investment in quality grows, there is demand for more scientific evidence on how to reliably improve quality of care in poor countries. USAID missions, and many other organizations spending on quality improvement, would welcome more information about how different strategies work to improve quality, when and where certain tools are most effective, and the best ways to measure success and shortcomings.

To gain a better understanding of the evidence supporting different quality improvement tools and clarity on how they would help advance the global quality improvement agenda, the Institute of Medicine convened a 2-day workshop in January 2015. The workshop's goal was to illuminate these different methods, discussing their pros and cons. This workshop summary is a description of the presentations and discussions.

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