Quality improvement of health systems in an epidemic context: A framework based on lessons from the Ebola virus disease outbreak in West Africa.

Quality improvement (QI) in health generally focuses on the provision of health services with the aim of improving service delivery. Yet QI can be applied not only to health services but also to health systems overall. This is of growing relevance considering that due to deficiencies in health systems, the main countries affected by Ebola virus disease (EVD) outbreak in West Africa (2014-2016) were insufficiently prepared for the epidemic, and according to the WHO, epidemics are increasingly becoming a threat to global health. Our objective is to analyze QI constraints in health systems during that EVD epidemic and to propose a practical framework for QI in health systems for epidemics in developing countries. We applied a framework analysis using experiences shared at the "Second International Quality Forum" organized by the University of Heidelberg and partners in July 2015 and information gathered from a systematic literature review. Empirical results revealed multiple deficiencies in the health systems. We systemized these shortfalls as well as the QI measures taken as a response during the epidemic. On the basis of these findings, we identified six specific "priority intervention areas," which ultimately resulted in the synthesis of a practical QI framework. We deem that this framework that integrates the priority intervention areas with the WHO building blocks is suitable to improve, monitor, and evaluate health system performance in epidemic contexts in developing countries.

Unpacking the black box of improvement.

During the Salzburg Global Seminar Session 565-'Better Health Care: How do we learn about improvement?', participants discussed the need to unpack the 'black box' of improvement. The 'black box' refers to the fact that when quality improvement interventions are described or evaluated, there is a tendency to assume a simple, linear path between the intervention and the outcomes it yields. It is also assumed that it is enough to evaluate the results without understanding the process of by which the improvement took place. However, quality improvement interventions are complex, nonlinear and evolve in response to local settings. To accurately assess the effectiveness of quality improvement and disseminate the learning, there must be a greater understanding of the complexity of quality improvement work. To remain consistent with the language used in Salzburg, we refer to this as 'unpacking the black box' of improvement. To illustrate the complexity of improvement, this article introduces four quality improvement case studies. In unpacking the black box, we present and demonstrate how Cynefin framework from complexity theory can be used to categorize and evaluate quality improvement interventions. Many quality improvement projects are implemented in complex contexts, necessitating an approach defined as 'probe-sense-respond'. In this approach, teams experiment, learn and adapt their changes to their local setting. Quality improvement professionals intuitively use the probe-sense-respond approach in their work but document and evaluate their projects using language for 'simple' or 'complicated' contexts, rather than the 'complex' contexts in which they work. As a result, evaluations tend to ask 'How can we attribute outcomes to the intervention?', rather than 'What were the adaptations that took place?'. By unpacking the black box of improvement, improvers can more accurately document and describe their interventions, allowing evaluators to ask the right questions and more adequately evaluate quality improvement interventions.

How do we learn about improving health care: a call for a new epistemological paradigm.

PURPOSE: The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions. QUESTIONS: We need to consider the following questions: (i) Did the improvements work? (ii) Why did they work? (iii) How do we know that the results can be attributed to the changes made? (iv) How can we replicate them? (Note, the goal is not to copy what was done, but to affect factors that can yield similar results in a different context.) NEXT STEPS: Answers to these questions will help improvers find ways to increase the rigor of their improvements, attribute the results to the changes made and better understand what is context specific and what is generalizable about the improvement.

Orphans of the Mexican drug war: insights on a public health challenge.

OBJECTIVE: To describe how the Government of Mexico and other direct stakeholders perceive children orphaned by the drug war; to determine the current measures addressing this as a public health problem; and to compare these measures to international frameworks so that relevant recommendations can be identified. METHODS: This was an exploratory, descriptive case study using qualitative methods. Semi-structured interviews were performed with key informants at the federal, state, and municipal government levels in Mexico, as well as non-governmental organizations, and other institutes working with orphans. Participants were identified with a purposive snowball sample. RESULTS: No official definition of "orphan" was identified; nor was there a shared perception among the key informants of what constitutes being an orphan. An official, collective definition is important because it modifies the quantity of children categorized as such within the target population. Although most of the interviewees perceive that the number of orphans and vulnerable children (OVC) has increased in the last 6 years, they acknowledged there is no reliable data to prove it. The increase, they believe, is due not to the drug war, but to a loss of family cohesion. Stakeholders recommend improving public policies, currently identified as the most difficult barrier to overcome due to a perceived inability to modify existing laws. However, the General Law for Victims was recently passed by the Government of Mexico and addresses many of the challenges identified. CONCLUSIONS: When compared to the international frameworks, there are three major issues in Mexico's current situation: coordination among and within stakeholders; emphasis on using community solutions; and putting in place preventive programs. For two of these problems, the General Law of Victims offers solutions.

Orphans of the Mexican drug war: insights on a public health challenge / Huérfanos víctimas de la lucha contra el narcotráfico en México: apreciaciones sobre un reto en materia de salud pública

OBJECTIVE: To describe how the Government of Mexico and other direct stakeholders perceive children orphaned by the drug war; to determine the current measures addressing this as a public health problem; and to compare these measures to international frameworks so that relevant recommendations can be identified. METHODS: This was an exploratory, descriptive case study using qualitative methods. Semi-structured interviews were performed with key informants at the federal, state, and municipal government levels in Mexico, as well as non-governmental organizations, and other institutes working with orphans. Participants were identified with a purposive snowball sample. RESULTS: No official definition of "orphan" was identified; nor was there a shared perception among the key informants of what constitutes being an orphan. An official, collective definition is important because it modifies the quantity of children categorized as such within the target population. Although most of the interviewees perceive that the number of orphans and vulnerable children (OVC) has increased in the last 6 years, they acknowledged there is no reliable data to prove it. The increase, they believe, is due not to the drug war, but to a loss of family cohesion. Stakeholders recommend improving public policies, currently identified as the most difficult barrier to overcome due to a perceived inability to modify existing laws. However, the General Law for Victims was recently passed by the Government of Mexico and addresses many of the challenges identified. CONCLUSIONS: When compared to the international frameworks, there are three major issues in Mexico's current situation: coordination among and within stakeholders; emphasis on using community solutions; and putting in place preventive programs. For two of these problems, the General Law of Victims offers solutions.

OBJETIVO: Describir cómo el Gobierno de México y otros interesados directos perciben el tema de los niños huérfanos como consecuencia de la lucha contra el narcotráfico; determinar las iniciativas actuales que abordan este tema como un problema de salud pública; y comparar estas iniciativas con los marcos internacionales con objeto de poder determinar las recomendaciones pertinentes. MÉTODOS: Se trata de un estudio de casos exploratorio y descriptivo que utilizó métodos cualitativos. Se llevaron a cabo entrevistas semiestructuradas con informantes clave a escalas federal, estatal y municipal del gobierno de México, así como con organizaciones no gubernamentales y otras instituciones que colaboraban con los huérfanos. Los participantes fueron seleccionados mediante un muestreo intencionado de bola de nieve. RESULTADOS: No se encontró ninguna definición oficial de "huérfano"; ni existía entre los informantes clave una percepción compartida de lo que constituye ser un huérfano. Es importante que exista una definición oficial y colectiva porque modifica la cantidad de niños clasificados como tales entre la población examinada. Aunque la mayor parte de los entrevistados perciben que el número de niños huérfanos y vulnerables (NHV) ha aumentado en los seis últimos años, también reconocen que no existen datos fidedignos que lo demuestren. Creen que el aumento no se debe a la lucha contra el narcotráfico sino a una pérdida de la cohesión familiar. Los interesados directos recomiendan mejorar las políticas públicas, que actualmente se consideran como la barrera más difícil de superar, dada la incapacidad percibida para modificar las leyes existentes. Sin embargo, el Gobierno de México aprobó recientemente la Ley General de Víctimas, que aborda muchos de los retos señalados. CONCLUSIONES: En comparación con los marcos internacionales, existen tres asuntos principales en la situación actual de México: la coordinación entre y dentro de los distintos grupos de interesados directos; el énfasis en el empleo de soluciones comunitarias; y la implantación de programas preventivos. La Ley General de Víctimas ofrece una solución para dos de estos problemas.

Local perceptions on factors influencing the introduction of international healthcare accreditation in Pakistan.

One contributor to poor health outcomes in developing countries is weak health systems; key to strengthening them are interventions to improve quality of health services. Though the value of healthcare accreditation is increasingly recognized, there are few case studies exploring its adaptation in developing countries. The aim of our study in Pakistan was to identify perceived factors influencing the adaptation of international healthcare accreditation within a developing country context. We used qualitative methods including semi-structured interviews, a structured group discussion, focus groups and non-participant observation of management meetings. Data analysis used a grounded theory approach and a conceptual framework adapted from implementation science. Using our conceptual framework categories of 'inner' and 'outer' setting, we found six perceived inner health system factors that could influence the introduction of healthcare accreditation and two 'outer' setting factors, perceived as external to the health system but able to influence its introduction. Our research identified that there is no 'one size fits all' approach to introducing healthcare accreditation as a means to improve healthcare quality. Those planning to support healthcare accreditation, such as national and provincial ministries and international development partners, need to understand how the three components of healthcare accreditation fit into the local health system and into the broader political and social environment. In our setting this included moving to supportive and transparent external evaluation mechanisms, with a first step of using locally developed and agreed standards. In addition, sustainable implementation of the three components was seen as a major challenge, especially establishment of a well-managed, transparent accreditation agency able to lead processes such as training and support for peer surveyors. Consideration of local change mechanisms and cultural practices is important in designing a local accreditation approach. The results of our study are important for health systems strengthening in Pakistan and in other developing countries.

Charting the way forward to better quality health care: how do we get there and what are the next steps? Recommendations from the Salzburg Global Seminar on making health care better in low- and middle-income economies.

OBJECTIVE: In April 2012, the Salzburg Global Seminar (SGS) brought together 58 health leaders from 33 countries to review experiences in improving the quality and safety of health-care services in low- and middle-income countries, synthesize lessons learned from those experiences, discuss challenges and opportunities and recommend next steps to stimulate improvement in such countries. This work summarizes the seminar's key results, expressed as five shared challenges and five lessons learned. DESIGN: The seminar featured a series of interactive sessions with an all-teach, all-learn approach. Session topics were: introduction to the seminar, journey to date, challenges that lie ahead, overcoming the issues of confusion, sustaining execution, strengthening leadership and policy, the role of quality improvement in health systems strengthening and setting the agenda for learning and next steps. RESULTS: Key lessons from the SGS include reducing terminology and methodology confusion, strengthening the learning agenda, embracing improvement science as a means for strengthening health-care systems, developing leadership in improving health care and ensuring that health-care systems focus on patients and communities. A call to action was developed by SGS participants and presented at the 65th World Health Assembly in Geneva. CONCLUSION: There is an inarguable need to move improvement in health care to a new level to attain and exceed the Millennium Development Goals. The challenges can be overcome through concerted action of key stakeholders and the application of scientifically grounded management methods to enable the reliable implementation of high-impact interventions for every patient every time needed.

Corporate social responsibility in countries with mature and emerging pharmaceutical sectors / Responsabilidad social corporativa en países con sectores farmacéuticos maduros y emergentes

In recent decades the concept of Corporate Social Responsibility (CSR) has been adopted by many business sectors, including the pharmaceutical industry. However, in this and other sectors its application remains variable, particularly between mature and developing economies. Its stakeholders include pharmacy and medical students, their attitude to the involvement of companies in socially responsible activities will be important determinants of public response to the industry. Objective: To investigate the knowledge, attitudes and practices of senior medical and pharmacy students towards the CSR concept in the pharmaceutical sector in mature (Germany) and developing (Russia) markets. Methods: A questionnaire survey was carried out among senior pharmacy and medical students during the summer semester 2008 in two Russian and one German university. In each country 120 questionnaires were distributed. The response rate was 95% in Russia and 93% in Germany. Results: Although the relevance of CSR was widely acknowledged by the students, very few were aware of CSR practices currently performed by companies. The reputation of the pharmaceutical industry was generally poor: less than 15% of respondents gave credence to the information provided in advertisements and fully supported pricing strategies as well as policies towards the developing countries. When choosing an employer more than 90% of respondents consider the policies affecting an employee directly as pivotal. However, for a high proportion of students (59% in Russia and 64% in Germany) socially irresponsible behavior by companies has a significant negative impact. Conclusions: This paper identifies practices which students believe should be a part of the CSR programmes for the pharmaceutical industry, and also some that should be abandoned. It recommends that corporate communication on CSR should be expanded. Key differences are seen in perceptions of students in Germany and Russia towards the extent of irresponsible actions and the variation between them (AU)

En las últimas décadas, el concepto de responsabilidad social corporativa (RSC) ha sido adoptado por muchos sectores empresariales, incluyendo la industria farmacéutica. Sin embargo, tanto en este como en otros sectores, su aplicación es variable, particularmente entre las economías maduras y en desarrollo. Entre los decisores se encuentran los estudiantes de farmacia y medicina, y su actitud ante la participación de las empresas en actividades socialmente responsables será un determinante importante de la respuesta del público ante la industria. Objetivo: Investigar el conocimiento, actitudes y prácticas de los estudiantes de últimos años de farmacia y medicina sobre el concepto de RSC en los mercados farmacéuticos maduros (Alemania) y en desarrollo (Rusia). Métodos: Se realizó una investigación entre estudiantes de últimos años de farmacia y medicina durante el semestre de verano de 2008 en dos universidades rusas y una alemana. En cada país se distribuyeron 120 cuestionarios. La tasa de respuesta fue del 95% en Rusia y del 93% en Alemania. Resultados: Aunque la importancia de la RSC fue reconocida por los estudiantes, muy pocos conocía las prácticas de RSC actualmente realizadas por las empresas. La reputación de la industria farmacéutica era en general pobre: menos del 15% de los respondentes daba crédito a la información proporcionada en los anuncios y apoyaba completamente estrategias de precios así como políticas para países en desarrollo. Cuando seleccionaban un empleo, más del 90% de los respondentes consideró las políticas que afectan al empleador como críticas. Sin embargo, para una alta proporción de estudiantes (59% en Rusia y 64% en Alemania) las actitudes socialmente irresponsables de las empresas tenía un significativo impacto negativo. Conclusiones: Este artículo identifica las prácticas que los estudiantes creen que deberían formar parte de los programas de RSC de la industria farmacéutica, así como los que deberían abandonar. Se recomienda que se aumente la comunicación corporativa sobre la RSC. SE han visto diferencias clave en la percepción de los estudiantes en Alemania y Rusia sobre la extensión de las acciones irresponsables y la variedad de ellas (AU)

Key quality aspect: a fundamental step for quality improvement in a resource-poor setting.

The objective of the study is to identify user's perception of key quality aspects of the hospital and its influence on willingness to pay. The study was conducted in 2001 in Dhading District Hospital, Nepal. This was a descriptive, cross-sectional study design using quantitative and qualitative methods: questionnaire exit interview and focus group discussions with inpatients and outpatients, focus group discussion with service providers, and key informant interviews. The research identified attitude, technical and interpersonal skills of health personnel, availability of drugs and services as important quality aspects to be improved. Users were motivated to use this hospital and were ready to pay if they received proper treatment from skilled and communicative staff. This study highlights the importance of identifying the quality factors important to service users as a first step in improving quality. For the users within this study, this meant improving attitude, interpersonal skills, and technical skills of service personnel.

Corporate social responsibility in countries with mature and emerging pharmaceutical sectors.

UNLABELLED: In recent decades the concept of Corporate Social Responsibility (CSR) has been adopted by many business sectors, including the pharmaceutical industry. However, in this and other sectors its application remains variable, particularly between mature and developing economies. Its stakeholders include pharmacy and medical students, their attitude to the involvement of companies in socially responsible activities will be important determinants of public response to the industry. OBJECTIVE: To investigate the knowledge, attitudes and practices of senior medical and pharmacy students towards the CSR concept in the pharmaceutical sector in mature (Germany) and developing (Russia) markets. METHODS: A questionnaire survey was carried out among senior pharmacy and medical students during the summer semester 2008 in two Russian and one German university. In each country 120 questionnaires were distributed. The response rate was 95% in Russia and 93% in Germany. RESULTS: Although the relevance of CSR was widely acknowledged by the students, very few were aware of CSR practices currently performed by companies. THE REPUTATION OF THE PHARMACEUTICAL INDUSTRY WAS GENERALLY POOR: less than 15% of respondents gave credence to the information provided in advertisements and fully supported pricing strategies as well as policies towards the developing countries. When choosing an employer more than 90% of respondents consider the policies affecting an employee directly as pivotal. However, for a high proportion of students (59% in Russia and 64% in Germany) socially irresponsible behavior by companies has a significant negative impact. CONCLUSIONS: This paper identifies practices which students believe should be a part of the CSR programmes for the pharmaceutical industry, and also some that should be abandoned. It recommends that corporate communication on CSR should be expanded. Key differences are seen in perceptions of students in Germany and Russia towards the extent of irresponsible actions and the variation between them.