Quality healthcare in extreme adversity: Developing a framework for action.

Quality issue: Improving quality of care has become a global health priority to improve health outcomes and strengthen health systems, particularly in the context of achieving universal health coverage. Initial assessment: The delivery of quality essential health services in settings of extreme adversity, such as fragile, conflict-affected, vulnerable or disaster contexts, has been identified as a high priority globally to address the massive level of need. Choice of solution: This paper provides an action framework to systematically address the quality of health services for state and non-state actors working in such settings. The framework is designed to be practical, comprehensible and simple in adoption and implementation. It describes challenges, a set of medical needs and population priorities, a menu of quality-related interventions, and a hierarchy of health system levels defining the roles and responsibilities of key actors. Conclusion: Optimizing the use of limited resources in delivering the best quality possible in 'the hardest of the hard settings' is imperative.

Institutionalizing quality within national health systems: key ingredients for success.

Quality improvement initiatives can be fragmented and short-term, leading to missed opportunities to improve quality in a systemic and sustainable manner. An overarching national policy or strategy on quality, informed by frontline implementation, can provide direction for quality initiatives across all levels of the health system. This can strengthen service delivery along with strong leadership, resources, and infrastructure as essential building blocks for the health system. This article draws on the proceedings of an ISQua conference exploring factors for institutionalizing quality of care within national systems. Active learning, inclusive of peer-to-peer learning and exchange, mentoring and coaching, emerged as a critical success factor to creating a culture of quality. When coupled by reinforcing elements like strong partnerships and coordination across multiple levels, engagement at all health system levels and strong political commitment, this culture can be cascaded to all levels requiring policy, leadership, and the capabilities for delivering quality healthcare.

Quality health care in extreme adversity-an action framework.

QUALITY PROBLEM OR ISSUE: There are record-setting numbers of people living in settings of extreme adversity and they continue to increase each year. INITIAL ASSESSMENT: There is a paucity of validated data on quality and safety across settings of extreme adversity. CHOICE OF SOLUTION: This paper argues for an action framework to address the unique challenges of providing quality in extreme adversity. IMPLEMENTATION: We describe a preliminary Quality in Extreme Adversity framework which has been informed by-and will continue to be validated through-literature, data collection, WHO expert consultations and through working in settings of extreme adversity with national authorities and NGOs. LESSONS LEARNED: Poor quality care costs lives, livelihoods and trust in health services. The recommended framework, based on evidence and experiential lessons, intends to address the WHO goal for 2019-2023 of 'one billion people better protected from health emergencies' (9).

Quality improvement and emerging global health priorities.

Quality improvement approaches can strengthen action on a range of global health priorities. Quality improvement efforts are uniquely placed to reorient care delivery systems towards integrated people-centred health services and strengthen health systems to achieve Universal Health Coverage (UHC). This article makes the case for addressing shortfalls of previous agendas by articulating the critical role of quality improvement in the Sustainable Development Goal era. Quality improvement can stimulate convergence between health security and health systems; address global health security priorities through participatory quality improvement approaches; and improve health outcomes at all levels of the health system. Entry points for action include the linkage with antimicrobial resistance and the contentious issue of the health of migrants. The work required includes focussed attention on the continuum of national quality policy formulation, implementation and learning; alongside strengthening the measurement-improvement linkage. Quality improvement plays a key role in strengthening health systems to achieve UHC.

Improving water, sanitation and hygiene in health-care facilities, Liberia.

PROBLEM: The lack of proper water and sanitation infrastructures and poor hygiene practices in health-care facilities reduces facilities' preparedness and response to disease outbreaks and decreases the communities' trust in the health services provided. APPROACH: To improve water and sanitation infrastructures and hygiene practices, the Liberian health ministry held multistakeholder meetings to develop a national water, sanitation and hygiene and environmental health package. A national train-the-trainer course was held for county environmental health technicians, which included infection prevention and control focal persons; the focal persons acted as change agents. LOCAL SETTING: In Liberia, only 45% of 701 surveyed health-care facilities had an improved water source in 2015, and only 27% of these health-care facilities had proper disposal for infectious waste. RELEVANT CHANGES: Local ownership, through engagement of local health workers, was introduced to ensure development and refinement of the package. In-county collaborations between health-care facilities, along with multisectoral collaboration, informed national level direction, which led to increased focus on water and sanitation infrastructures and uptake of hygiene practices to improve the overall quality of service delivery. LESSONS LEARNT: National level leadership was important to identify a vision and create an enabling environment for changing the perception of water, sanitation and hygiene in health-care provision. The involvement of health workers was central to address basic infrastructure and hygiene practices in health-care facilities and they also worked as stimulators for sustainable change. Further, developing a long-term implementation plan for national level initiatives is important to ensure sustainability.