A milestone in global efforts to improve health care
Last month marked the closing of the USAID Health Care Improvement (HCI) Project, the largest global effort to date to improve health care quality in lower- and middle-income countries (LMICs). A seven-year USAID project that operated in 38 countries, HCI built on earlier USAID-funded projects and the experience of high-income countries to directly examine both clinical and non-clinical health care activities and develop ways to improve them.
One of the major findings of the published literature in the field of quality improvement (QI) is that attempts to improve quality are complex social interventions—efforts with the same label may have substantial differences, and the results of a given intervention cannot be predicted with confidence in the way we do, for example, with drug trials. On this basis, HCI did not select one or more specific methodologies for addressing quality issues, but rather chose a general approach for organizing QI efforts that would generate evidence of effectiveness for every application—an evidence-based approach to improving health care processes. This approach is generally known as continuous quality improvement (CQI). CQI has been extensively used in the US health care system, and prior to that, in industry.
The basic mechanism of improvement in CQI is tests of change—identifying a promising change in a health care process and then conducting a small scale trial of that change, measuring an indicator for the outcome of that process. Changes that show improvement can then be scaled up based on evidence. A central feature of CQI is that these tests are carried out by teams of health workers, not external advisors. A major lesson from HCI is that health workers across a wide range of settings have demonstrated the capacity to conduct and analyze these tests.
HCI also incorporated a major advance in CQI developed in the US: Shared learning among improvement teams. US experience demonstrated more rapid improvement when multiple teams worked on the same area and shared what they were learning. This modification proved to be even more valuable in LMICs, especially through the motivation provided by an extended peer group. This “collaborative improvement” approach was also designed to work with existing resources.
A new report summarizes the achievements and key learning from HCI. Much of the report focuses on the effectiveness of CQI across all USAID priority health issues. The report also summarizes the results of seven formal evaluations of country QI programs and 26 papers published in peer-reviewed journals. The technical and research reports and papers produced by HCI also describe the largest program of research and evaluation for QI in LMICs ever conducted. Appendices provide baseline values for nearly 400 quality indicators, and the level of these indicators after a QI intervention. The volume of quantitative measures of quality in this report is unprecedented in the published or gray literature.
There is, of course, some variability in the results from such a large number of QI applications, but there is one overwhelming impression: impressive levels of improvement, consistently achieved across a wide range of country settings and health topics. The research and evaluation component contributes important insights, particularly through its focus on the cost-effectiveness of these QI applications.
A substantial learning agenda remains, including better understanding of the institutionalization of QI as a permanent, integral part of health services, the sustainability of improved processes, the factors in successful scaling up, the application of QI to management issues, increasing the efficiency and productivity of health care processes, and expanding the effective use of knowledge management related to tests of change. Readers of this report will want to reflect on the implications of this body of evidence for global health.