Model for building quality resilient health facility.

The AfIHQSA Model is the model for building quality resilient health systems. It is proposed as a compliment to and in many instances as an alternative to the many other existing in ensuring a systematic and a sustained approach to improving outcomes in African health systems. It seeks to bring the necessary transformation to healthcare quality and patient safety and facilitate the attainment of desired outcomes. The model is unique in its iterative nature and how it places premium on sustaining the gains of improvement. The authors are concerned about the lack of sustainability of the many quality improvement efforts on the continent and how they all fade out into obscurity upon the exit of the proponents. Six iterative steps are proposed in the use of the model and these are: leadership commitment and buy-in; situational analysis of quality management capacity; systems strengthening for quality management; quality improvement interventions for care outcomes; standardization/accreditation/certification; and iterative monitoring, evaluation of performance of interventions and learning. Most of the quality interventions and efforts on the continent have failed because the steps in this model have not been sufficiently followed and addressed. The required strengthening of the various components of the health system necessary to sufficiently bear the weight of any quality intervention and guarantee sustainability of the gains is often ignored. As authors, we have therefore formally adopted the use of this model and plan to further continue evaluating and monitoring its utility and its generalizability in different institutions and countries.

Empanelment: A foundational component of primary health care.

Empanelment is a foundational strategy for building or improving primary health care systems and a critical pathway for achieving effective universal health coverage. However, there is little international guidance for defining empanelment or understanding how to implement empanelment systems in low- and middle-income countries. To fill this gap, a multi-country collaborative within the Joint Learning Network for Universal Health Coverage developed this empanelment overview, proposing a people-centered definition of empanelment that reflects the responsibility to proactively deliver primary care services to all individuals in a target population. This document, building on existing literature on empanelment and representing input from 10 countries, establishes standard concepts of empanelment and describes why and how empanelment is used. Finally, it identifies key domains that may influence effective empanelment and that must be considered in deciding how empanelment can be implemented. This document is designed to be a useful resource for health policymakers, planners and decision-makers in ministries of health, as well as front line providers of primary care service delivery who are working to ensure quality people-centered primary care to everyone everywhere.

The effect of the National Health Insurance Scheme (NHIS) on health service delivery in mission facilities in Ghana: a retrospective study.

BACKGROUND: In 2004, Ghana began implementation of a National Health Insurance Scheme (NHIS) to minimize out-of-pocket expenditure at the point of use of service. The implementation of the scheme was accompanied by increased access and use of health care services. Evidence suggests most health facilities are faced with management challenges in the delivery of services. The study aimed to assess the effect of the introduction of the NHIS on health service delivery in mission health facilities in Ghana. We conceptualised the effect of NHIS on facilities using service delivery indicators such as outpatient and inpatient turn out, estimation of general service readiness, revenue and expenditure, claims processing and availability of essential medicines. We collected data from 38 mission facilities, grouped into the three ecological zones; southern, middle and northern. Structured questionnaires and exit interviews were used to collect data for the periods 2003 and 2010. The data was analysed in SPSS and MS Excel. RESULTS: The facilities displayed high readiness to deliver services. There were significant increases in outpatient and inpatient attendance, revenue, expenditure and improved access to medicines. Generally, facilities reported increased readiness to deliver services. However, challenging issues around high rates of non-reimbursement of NHIS claims due to errors in claims processing, lack of feedback regarding errors, and lack of clarity on claims reporting procedures were reported. CONCLUSION: The implementation of the NHIS saw improvement and expansion of services resulting in benefits to the facilities as well as constraints. The constraints could be minimized if claims processing is improved at the facility level and delays in reimbursements also reduced.

A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation progress.

QUALITY PROBLEM: The gap between evidence-based guidelines and practice of care is reflected, in low- and middle-income countries, by high rates of maternal and child mortality and limited effectiveness of large-scale programing to decrease those rates. CHOICE OF SOLUTION: We designed a phased, rapid, national scale-up quality improvement (QI) intervention to accelerate the achievement of Millennium Development Goal Four in Ghana. Our intervention promoted systems thinking, active participation of managers and frontline providers, generation and testing of local change ideas using iterative learning from transparent district and local data, local ownership and sustainability. IMPLEMENTATION: After 50 months of implementation, we have completed two prototype learning phases and have begun regional spread phases to all health facilities in all 38 districts of the three northernmost regions and all 29 Catholic hospitals in the remaining regions of the country. To accelerate the spread of improvement, we developed 'change packages' of rigorously tested process changes along the continuum of care from pregnancy to age 5 in both inpatient and outpatient settings. LESSONS LEARNED: The primary successes for the project so far include broad and deep adoption of QI by local stakeholders for improving system performance, widespread capacitation of leaders, managers and frontline providers in QI methods, incorporation of local ideas into change packages and successful scale-up to approximately 25% of the country's districts in 3 years. Implementation challenges include variable leadership uptake and commitment at the district level, delays due to recruiting and scheduling barriers, weak data systems and repeated QI training due to high staff turnover.